THE 



THEORY AND PRACTICE OF MEDICINE. 



WORKS ON PRACTICE, 



BY AUSTIN FLINT, M.D., 

Professor of the Prhiciples and Practice of Medicine and of Clinical Medicine in the Bellevue 
Hospital Medical College, New York. 



A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE, 

Designed for the use of Students and Practitioners of Medicine. 
Fourth Edition Revised and Enlarged In one large and closely printed octavo 
volume of nearly 1100 pages. Cloth, $6; leather, $7. (Lately issued.) 

Has never been surpassed as a text-book for students, and a book of ready reference for practitioners 
The force of its logic, its simple and practical teachings, have left it without a rival in the field— New 
York Medical Record, September 15th, 1S74. 

It is given to very few men to tread in the steps of Austin Flint, whose single volume on Medicine 
though here and there defective, is a masterpiece of lucid condensation and of general grasp of an enor- 
mously wide subject.— London Practitioner, December, 1873. 

PHTHISIS— ITS MORBID ANATOMY, SYMPTOMATIC EVENTS AND 
COMPLICATIONS, FATALITY AND PROGNOSIS, TREATMENT 
AND PHYSICAL DIAGNOSIS, in a series of Clinical Studies. In 
one large and handsome octavo volume of 446 pages. Cloth, $3.50. (Just issued.) 

Dr. Flint is one of those who is satisfied only with personal investigation, he is exceeding fair in argu- 
ment and remarkably apt in analyzing cases. We trust the hook will he verv generally read, as it will 
be found a valuable result of laborious preparation.— New York MedicalJourndl , April, 1876. 

A MANUAL OF PERCUSSION AND AUSCULTATION ; OF THE PHYSICAL 
DIAGNOSIS OF DISEASES OF THE LUNGS AND HEART, AND OF 
THORACIC ANEURISM. In one handsome royal 12mo. volume of 255 
pages. Cloth, $1.75. (Now ready.) 

The manual before us will be eagerly sought by all who conscientiously desire to be skilful practition- 
ers of medicine, and, we hardly need say, will meet all reasonable expectations. We cordially commend 
this valuable manual to the profession at large, but more especially to the large number of students who 
can scarcely afford to omit purchasing and reading it.— St. Louis Clinical Record, September, 1876. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORATION OF THE 
CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and Revised Edition. In one handsome 
octavo volume of 595 pages. Cloth, $4.50. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND 
TREATMENT OF DISEASES OF THE HEART. Second Revised and 
Enlarged Edition. In one octavo volume of 550 pa^es, with a plate. Cloth, 
$4.00. • P 



ESSAYS ON CONSE RYATI YE MEDICINE AND KINDRED TOPICS. In 
one very handsome royal 12mo. volume of 214 pages. Cloth, $1.38. (Just 

issued.) 



HEERY C. LEA. 



A TREATISE 



ON THE 



Theory and Practice of Medicine, 



BY 



JOHN SYER BRISTOWE, M.D, Lond., F.R.C.P., 

PHYSICIAN TO ST. THOMAS'S HOSPITAL, JOINT-LECTURER ON MEDICINE AT THE SCHOOL, AND EXAMINER 
IN MEDICINE TO THE ROYAL COLLEGE OF SURGEONS; FORMERLY EXAMINER IN 
MEDICINE TO THE UNIVERSITY OF LONDON, AND LECTURER ON 
GENERAL PATHOLOGY AND ON PHYSIOLOGY 
AT ST. THOMAS'S. HOSPITAL. 



EDITED, WITH NOTES, 

BY 

JAMES H. HUTCHINSON, M.D., 

ONE OF THE ATTENDING PHYSICIANS TO THE PENNSYLVANIA HOSPITAL; PHYSICIAN 
TO THE CHILDREN'S HOSPITAL, PHILADELPHIA, ETC. 




PHILADELPHIA: 



HENRY C. LEA. 
OO 1 8 7 6. 



<0 



Entered according to Act of Congress, in the year 1876, 
By HENRY C. LEA, 
the office of the Librarian of Congress at Washington, D. C. 



PHILADELPHIA: 
SHERMAN & CO., PRINTERS. 



PEEFACE TO THE AMEKICAN EDITION. 



The modest preface with which Dr. Bristowe introduces to the pro- 
fession his work on The Theory and Practice of Medicine might pos- 
sibly mislead the reader, who looked no farther, into thinking that the 
omission of reports of illustrative cases, or the failure to discuss fully 
questions pertaining to differential diagnosis, rendered it incomplete. 
So far is this from being the case, that the editor knows of no other work 
in which the author has been equally successful in bringing within 
the compass of a single volume the description of so large a number 
of diseases — some of which are not always included in works on Prac- 
tice, as, for instance, diseases peculiar to women, and of the skin — and 
in doing this in a manner as advantageous to the student. Where so 
much is excellent it is difficult to particularize, but the editor would 
call attention specially to the section on Tumors, in which the author 
shows that he has thoroughly mastered a very difficult subject. 

The work is designed principally as a text-book for students in 
Medicine, whose wants it certainly meets fully. But the editor has 
found the task of preparing the American edition for the press so 
profitable, as well as pleasant, that he believes the practitioner who is 
anxious to keep himself acquainted w T ith the progress of Medicine will 
find it a useful book to consult, since it is thoroughly representative 
of the present condition of Practical Medicine, as regards both the 
treatment and the diagnosis of disease. 

In a few places it has seemed to the editor that the value of the 
work, especially to the American student, would be increased by the 
addition of a few notes, which will be found distributed throughout 
the volume, and are distinguishable from the body of the text by being 



vi 



PREFACE TO THE AMERICAN EDITION. 



enclosed in brackets [ — ]. They have been made in harmony, as far 
as possible, with the general plan of the work, and it is earnestly 
hoped that they will not be thought unworthy of the place they 
occupy. 

J. H. H. 

2019 Walnut Street, Philadelphia, 
September 26th, 1876. 



PEEFACE. 



In placing this work before those for whom it was especially written, 
namely, the junior members of the profession and students in Medicine, 
I may be permitted to make a few preliminary remarks, partly by way 
of explanation, partly by way of acknowledgment, partly apologetic. 

The first thought, as I suppose, of every one who sits down to write 
a scientific book is bestowed upon the arrangement of his matter. It 
was my first thought. The classification of disease, moreover, is a 
subject to which I have devoted a good deal of attention. But I had 
long formed the opinion that it is impossible, in a work on Medicine, 
intended to be practical, to arrange diseases on strictly scientific prin- 
ciples ; and in this opinion further consideration of the matter only 
confirmed me. Consequently the arrangement which I have adopted 
is for the most part artificial, and to be defended only on grounds of 
convenience. Certain affections I have grouped together as " Specific 
Febrile Diseases but all others, with in many cases more or less dis- 
regard of accuracy, have been classified as Local Diseases. I may add 
that, in respect of the diseases of individual organs, I have for the 
most part arranged them, though without expressly indicating the fact, 
in the following order, namely, Inflammations, Morbid Growths (in- 
cluding Tubercular and Syphilitic Formations), Parasitic Diseases, 
Degenerations, and Mechanical and Functional Affections. I have 
not hesitated, however, in many instances, to depart from this arrange- 
ment. 

The selection of subjects to be discussed in a treatise intended to oc- 
cupy a moderate compass is by no means easy. Medicine is inextri- 
cably interwoven with Surgery and with what it is now fashionable to 
term " gynaecological medicine.' 7 Moreover, several other departments 
of practice, especially perhaps insanity, are now relegated to specialists, 
and have attained such importance as to need special hospitals, and to 
have a literature of their own. And again, many diseases, and more 
particularly local diseases, which doubtless have a substantial existence, 



Vlll 



PREFACE. 



are either not recognizable by specific symptoms during life, or are of 
very trivial importance, so that it would be a waste of time and space 
even to enumerate them. I trust that, under such circumstances, I 
shall be pardoned for having treated some important subjects super- 
ficially, for having omitted many subjects that it may seem to some 
persons that I should have included in my work, and for having occa- 
sionally introduced topics which may appear to be beyond the sphere 
of Medicine in the restricted sense of that term. 

In discussing each subject, and more especially in discussing each 
disease, my aim has been to give in a readable form as much informa- 
tion as I could include within a limited space. With that object, my 
practice has been in every case to read the subject up carefully, to 
compare the knowledge thus acquired or renewed with the results of 
my own experience, in those cases in which I had any experience, and 
then, having taken a more or less definite view of the whole subject, 
and while my mind was still full of it and of its details, to write as 
clear and as comprehensive an account as I was capable of. Each 
article may therefore be regarded as expressing in a condensed form 
the fulness of my knowledge of its subject at the moment at which it 
was written. This method of procedure will partly explain both the 
ex cathedra tone in which I have, I believe, generally expressed myself, 
the prevailing absence of notes, quotations, and references to authorities, 
and perhaps also many inaccuracies and omissions. 

I have, throughout the work, given particular prominence to the 
pathology and to the clinical phenomena of disease ; and in all cases 
in which the clinical phenomena seem to be the direct consequences of 
definite lesions (especially, therefore, in the case of local diseases) my 
account of the morbid anatomy has been made to precede the clinical 
description. It may possibly, however, seem to be an omission that I 
have only occasionally devoted a special paragraph to the differential 
diagnosis of diseases. It is so far an omission that I have been driven 
to it by the exigencies of space. But on the whole I do not regret it ; 
for the distinguishing of one disease from another disease should de- 
pend, not on the simple recognition of a few leading characters, which, 
however carefully selected, are apt not unfrequently to fail us, but on 
a bona fide and thorough acquaintance with the collective phenomena 
of diseases. The more a student is taught to rely on one or two cri- 
teria, the less likely is he to investigate diseases intelligently, and the 
more apt is he to be content with hasty and inaccurate diagnoses. 



PREFACE. 



ix 



In respect of the treatment of diseases, again, I may appear to have 
been in many cases less full and less specific than I ought to have been. 
The principles by which I have been guided in this matter are easy to 
explain. In the first place, it seemed to me that works upon the Ma- 
teria Medica are the proper source from which to learn the doses in 
which medicine may be administered, and the best modes of combining 
medicines. And in the second place, in considering the details of 
treatment, as given in most works of medicine, it appeared to me that 
their authors had for the most part simply recommended those doses 
of drugs, those combinations of drugs, and those specific methods of 
administering them, to which they had accustomed themselves. I ad- 
mit that the subject of my last objection will be regarded by many 
from quite an opposite point of view. Nevertheless, while, on the one 
hand, I should hesitate to force my own routine and trivialities of 
practice upon students, I should equally hesitate to force upon them 
those of other people. It seems to me best, having inculcated general 
principles, and pointed out the specific virtues of certain drugs, to leave 
the young practitioner generally as much unshackled as possible with 
regard to his choice of particular combinations and modes of adminis- 
tration. He is far more likely to make a thoughtful physician and, 
as I think, to benefit his patient, if he adapts his drugs and his methods 
to the exigencies of cases as they present themselves before him, than 
if he follows the stereotyped procedure of some predecessor. 

From first to last I have carefully avoided quoting illustrative cases. 
This course has been forced upon me by the necessity under which I 
labored of compressing my work within the narrowest possible limits 
of space. But it is a course which I adopted reluctantly, and with 
the full knowledge that I was thereby robbing my pages of much that 
might have been instructive, of much, at any rate, that would have 
rendered them pleasanter reading. Every one who has perused them 
knows how much of the charm, the freshness, the vigor, the impres- 
siveness, and the permanent interest that characterize the classical 
writings of Abercrombie, of Graves, of Watson, of Trousseau, and of 
other masters of our art depend upon the well-told cases with which 
they are so richly interspersed. 

I have already referred to the omission to quote authorities of which 
I have been generally guilty. The excuses which I have to offer, in 
reference to this matter, are mainly the following : I was anxious to 
economize space ; I felt, moreover, that my work was not an encyclo- 



X 



PREFACE. 



psedia, still less a history, of Medicine ; and again, many important 
additions which have been made to onr knowledge, even during the 
last few years, have already become classical, and form an integral part 
of the great body of Medical Science. My indebtedness, however, 
direct or indirect, to innumerable writers and workers I most fully 
acknowledge; and among these I must not fail to include my senior 
colleagues and former teachers of St. Thomas's Hospital, the value of 
whose teaching to myself I cannot exaggerate. But there are certain 
works on which I have drawn very largely, and to the authors of 
which on that account I owe special gratitude; these are, in pathology 
and morbid anatomy, Rokitansky's Pathological Anatomy, Cornil and 
Ranvier's Manual of Pathological Histology, and Virchow's writings, 
including, above all, his marvellous work on the Pathology of Tumors; 
in general medicine, Sir T. Watsou's Lectures on the Principles and 
Practice of Physic, Reynolds's System of Medicine, Aitken's Science and 
Practice of Medioine, Niemeyer's Elements of Internal Pathology and 
Therapeutics, and Trousseau's Cliniccd Medicine ; and, in special sub- 
jects, Duchenne's admirable work on Localized Electrization, and the 
no less admirable Lectures by Charcot, on the Diseases of the Nervous 
System. 

I must apologize for the many omissions, errors, redundancies, and 
other faults with which I am only too conscious that my work abounds. 
Fresh from its completion, I feel, perhaps not unnaturally, how much 
better I could do it were I, from the standpoint of my present expe- 
rience, now to rewrite it. But this is perhaps a delusion. At any 
rate, I can only take credit for what I have done, and not for what I 
conceive myself capable of doing. The tree must be judged by its 
fruits. 

In conclusion, I beg leave to record my sincere thanks to my friends, 
Drs. H. Don kin and Greenfield for the kind and valuable assist- 
ance I have received from them in the progress of this work through 
the press. They have each read and criticized nearly every page ; and 
I owe it to them that many mistakes have been corrected, many omis- 
sions supplied, and that the reader has been spared the infliction of 
some grammatical inaccuracies and no little careless spelling. 

II Old Burlington Street, 

August, 1876. 



CONTENTS. 



PART I. 



PAGE 



GENERAL PATHOLOGY, .... 17 

The Definition of Disease, 17 

The ^Etiology of Disease, 21 

Predisposing Causes, ... . . . . . . . .22 

Age; sex; personal peculiarities; occupation, habits, etc.; previous 
disease ; heat and cold, etc. Epidemic constitution. Change of type of 
disease. 

Exciting Causes, ........... .27 

Mechanical; chemical; vital— parasites, contagia, malaria, etc. 

General Account of Physiological Processes in Health, . 32 
Properties and development of protoplasm. Simple tissues — epithe- 
lial, connective, tubular ; organs. Development, growth, and mainte- 
nance of the organism. Functions of circulatory system ; of digestive 
system ; of excretory system; of nervous system. Decay and death es- 
sential elements in the processes of life. 

Physiological Process in Disease, 37 

I. Morbid Growth, 38 

General Observations, . .... . ... . .38 

Growth and development of cells. Conditions associated with over- 
growth. Migration of leucocytes. Tendency of morbid growth to 
spread locally. Tendency of morbid growth to become generalized. 
Tendency of certain morbid growths to iimit their distribution to certain 
tissues or organs. Connection of dyscrasia with the origin of morbid 
growths. Secondary dyscrasia. Meaning of terms "malignant" and 
"innocent." 

Hypertrophy, . . . . . . . . • . . . . .46 

Inflammation, . . . . . . , . . . . . . .47 

General account. Extra vascular processes — in cartilage, in mesentery, 
in cornea, in the vascular tissues. Vascular processes. Exudation. Sup- 
puration. Destructive processes — ulceration, gangrene. Organization, 
granulation, and cicatrization. Spread. Constitutional effects. Varieties. 
Classification of Tumors, ........... 61 

General account. 



Xll 



CONTENTS. 



PAGE 

Connective-tissue Tumors (Group 1), . . . . . . . .63 

1. Fibrous tumor, or fibroma. 2. Fatty tumor, or lipoma. 3. Mucous 
tumor, or myxoma. 4. Glue-like tumor, or glioma. 
Cartilaginous Tumors, or Chondromata (Group 2), . . . . .65 

Eccbondroses ; enchondromata. 
Osseous Tumors, or Osteomata (Group 3), .66 

Ivory ; compact ; spongy. Exostoses. Enostoses. Odontomata. 
Nervous Tumors, or Neuromata (Group 4), . . . . . .66 

Muscular Tumors, or Myomata (Group 5), . . . . .67 

Vascular Tumors, or Angiomata (Group 6), . . . . . .67 

Simple; cavernous. 

Lymphatic Tumors, or Lymphomata (Group 7), . . . . .68 

1. Lymphangioma. 2. Lymphadenoma (lympho-sareoma) ; simple in- 
flammation ; scrofulous enlargement ; lympbadenoma ; leukasmia or leueo- 
cytbsemia. 

Tubercle and Granuloma (Group 8), . . . . . . . .73 



1. Tubercle: gray or miliary; caseous or yellow. Connection between 
tubercle and adenoid tissue. Relations between gray and yellow tubercle. 
Quasi- malignancy of tubercle. Experimental inoculation. 2. Syphil- 



itic gummata. 

Sarcomata (Group 9), 79 

1. Round-cell sarcoma. 2. Spindle-cell sarcoma. 3. Large-cell sar- 
coma. 4. Melanoid sarcoma. Psammoma. 
Carcinomata (Group 10), .......... 81 

1. Scirrhus or hard cancer. 2. Encephaloid cancer; erectile or hsema- 
toid, pultaceous, lipomatous, melanotic. 3. Colloid cancer. 4. Epithe- 
lioma or cancroid. 5. Adenoid or tubular cancer. 

II. Atrophy, Degeneration, and Necrosis, 87 

General Remarks. 1. Cloudy swelling. 2. Mucous and colloid degen- 



eration. 3. Lardaceous degeneration. 4. Fatty degeneration. 5. Pig- 
mentary degeneration. 6. Uratic degeneration. 7. Calcareous degenera- 
tion. Necrosis or Gangrene. 

III. Mechanical and Functional Derangements, 96 

a. Mechanical Derangements, .......... 96 

1. Displacement of parts. 2. Compression, contraction, and impac- 
tion. 3. Dilatation. Cysts: cysts by dilatation of natural cavities ; cysts 
by distension of ducts or retention ; cysts by extravasation ; cysts by 
softening of tissues. 4. Rupture and extravasation. 



b. Functional Derangements, . . .100 

1. Congestion, . . 101 

Active, passive. 

2. Dropsy, ' . .103 

Local, general. 

Fever, 105 



Normal temperature. Conditions which determine and regulate beat 
of body. Febrile temperature. Hyperpyrexia. Symptoms attending 
febrile temperature. Condition of skin ; of circulation ; of respiration ; 
of digestive organs ; of urine ; of nervous system. Cause of death in 
fever. Causes of the febrile temperature. The thermometer. 



CONTENTS. 



xiii 



PAGE 

Hectic Fever, . • • » • .113 

The Typhoid Condition, 114 

Symptoms. Causes. 

Collapse. Syncope, . . . . • . • • • • .116 
Symptoms of collapse. Symptoms of syncope. Depression of tem- 
perature. Feebleness of circulation. Condition of nervous functions. 

Death, . 118 

From failure of nutrition. From failure of the circulation. From 
failure of the elimination of effete and poisonous matters. From failure 
of the nervous system to perform its appropriate functions. 

The Treatment of Disease, 123 

Hygienic Treatment, ........... 123 

Prophylactic Treatment, . . . . . . . . . .123 

1. Prophylaxis in relation to the tendency, inherited or acquired, to 
disease. 2. Prophylaxis in relation to parasitic, endemic, and infec- 
tious disease. 3. Prophylaxis in relation to the complications or sequelae 
of disease. 

Remedial and Therapeutical Treatment, ....... 125 

1. Protection of sick from injurious influences. 2. The maintenance 
of the patient's strength. 3. The maintenance or improvement of the 
nutritive functions. 4. The elimination of effete matters. 5. The 
treatment of symptoms. 6. The obviation of the tendency to death. 



PART II. 

SPECIAL PATHOLOGY, . ... 131 
I.— SPECIFIC FEBRILE DISEASES, . . .131 

Introductory Remarks in reference mainly to the Infec- 
tious Fevers, 131 

Specific Origin and Spread of Epidemic and Endemic Diseases, . . .131 
They originate in specific causes. They prevail endemically or epi- 
demically. They are in large proportion infectious or contagious. 
Behavior of contagia within the organism. Behavior of contagia 
external to the body. Nature of contagia. 

General Rules to be observed in the Management of Epidemic and Contagious 



Diseases, .... . . . . . . . 137 

Influenza {Epidemic Catarrh), 140 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

Hooping-Cough {Pertussis), • .143 

Definition. Causation. Symptoms and progress. Morbid anatomy. 
Treatment. 

Mumps {Parotitis), 147 

Definition. Causation. Symptoms and progress. Morbid anatomy. 
Treatment. 



xiv 



CONTENTS. 



PAGE 

Measles (Bubeola. Morbilli), 149 

Definition. Causation. Symptoms and progress. Morbid anatomy. 
Treatment. 

Epidemic Eoseola (Botheln. Bubeola), 153 

Definition. Causation. Symptoms and progress. Treatment. 



Scarlet Fever (Scarlatina. Febris Bubra), 154 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

Small-Pox (Variola), 163 



Definition. Causation and history. Symptoms and progress. Va- 
rieties. Morbid anatomy. Treatment. 

Cow-Pox ( Vaccinia) Vaccination, 171 

Definition. Causation and relations with small-pox. Symptoms and 



progress in cattle. Symptoms and progress in man. Protective influ- 
ence of vaccination against small-pox. Dangers of vaccination. Per- 
formance of vaccination. 

Chicken-Pox (Varicella), 177 

Definition. Causation. Symptoms and progress. Treatment. 

Typhtts, . . '. . . ... 178 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

Plague (Pestilentia), • 186 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

Eelapsing Fever (Famine Fever), 187 

Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

Dekgue (Bandy Fever), 191 

Definition. Causation and history. Symptoms and progress. Treat- 
ment. 

Yellow Fever, 193 

Definition. Causation and history. S} r mptoms and progress. Mor- 
bid anatomy. Treatment. 

Cerebro-Spinal Fever (Epidemic Cerebro- Spinal Meningitis), . . 196 
Definition. Causation and history. Symptoms and progress. Mor- 
bid anatomy. Treatment. 

Diphtheria (Membranous Croup), 200 



Definition. Causation and history. Symptoms and progress. Va- 
rieties. Paralysis. Morbid anatomy and pathology. Treatment. 

Enteric Fever (Typhoid Fever. Abdominal Typhus), . . . 210 
Definition. Causation and History. Symptoms and progress. Va- 
rieties. Complications and sequelae. Diagnosis. Morbid anatomy. 
Treatment. 



CONTENTS. 



XV 



PAGE 

Epidemic Cholera (Asiatic or Malignant Cholera), .... 223 
Definition. Causation and history. Investigations daring English 
epidemics. Experimental production of cholera. Symptoms and prog- 
ress. Collapse. Keaction. Morbid anatomy and pathology. Treat- 
ment. Relations between cholera and summer diarrhoea. 

Hydrophobia (Babies), 236 

Definition. Causation and history. Symptoms and progress. Morbid 
anatomy. Treatment. 

Glanders. Farcy (Equinia), 239 

Definition. Causation and history. Symptoms and progress. Morbid 
anatomy. Treatment. 

Syphilis, 241 

Definition. Causation and history. Symptoms and progress. Pri- 
mary symptoms. Secondary symptoms. Tertiary symptoms. Inher- 
ited syphilis. Morbid anatomy and pathology. Treatment. 

Pyaemia {Septicaemia), 254 

Definition. Causation. Morbid anatomy and pathology. Symp- 
toms and progress. Treatment. 

Leprosy (Elephantiasis Grcecorum), . . .• . . . . 262 
Definition. Causation and history. Symptoms and progress. Va- 
rieties, tubercular and anaesthetic. Morbid anatomy and pathology. 
Treatment. 

Ague (Intermittent and Bemittent Fever), 268 

Definition. Causation and history. Symptoms and progress. In- 
termittent fever. Varieties. Remittent fever. Other varieties. Mor- 
bid anatomy and pathology. Treatment. 

II.— DISEASES OF THE SKIN, . . .278 
Introductory Remarks, 278 

Classification and Definition of Terms, . . . . . . 279 

1. Macula. 2. Exanthema, or rash. 3. Papula, or pimple. 4. 

Tubercles : wheal. 5. Vesicles. 6. Bulla?, or blebs. 7. Pustules. 8. 

Eurfura, or scurf. 9. Squama?, or scales. 10. Scab, or crust. 
Tendency of Spots and Patches of Skin Disease to assume a Circular Form, . 282 

Erysipelas, 283 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

Carbuncle (Anthrax). Boil (Furunculus), 288 

Definition. Causation. Morbid anatomy. Symptoms. Treatment. 

Erythema. Roseola. Urticaria. Pityriasis, .... 290 

Causation and description. 1. Erythema simplex ; pityriasis simplex. 
2. Erythema multiforme; varieties. 3. Erythema nodosum. 4. Ery- 
thema fugax. 5. Roseola. 6. Urticaria, or Nettle-rash ; varieties. 
Treatment. 

Psoriasis (Lepra). Pityriasis Kubra, ...... 296 

Psoriasis, . . . . . . . . . . . 296 

Causation and description. Varieties. Treatment. 



xvi 



CONTENTS. 



PAGE 

Pityriasis Rubra, .......... . 298 

Description. Treatment. 

Ichthyosis, 298 

Ichthyosis Simplex, or Xeroderma, ........ 299 

Description. Treatment. 
Ichthyosis Cornea, ........... 299 

Description. Treatment. 

Eczema [Lichen. Strophulus), 300 

Causation and description. Varieties. Treatment. 

Impetigo (Ecthyma), 304 

Causation and description. Varieties. Treatment. 

Sudamina. Miliaria, 306 

Description. 

Herpes. Pemphigus, 306 

Herpes, 306 

Causation and description. Varieties: 1. Zona, or Herpes zoster; 
2. H. simplex ; 3. H. iris; 4. H. circinahcs. Treatment. 

Pemphigus, ............ 309 

Causation and description. Varieties. Treatment. 

Eupia, . . , , . 311 

Causation and description. Varieties. Treatment. 

Inflammation of the Sebaceous Glands. Acne, . . . 312 
Seborrhea, ............ 312 

Causation and description. Treatment. 
Acne, 312 

Causation and description. Varieties. Treatment. 
Acne Rosacea, ............ 314 

Causation and description. Treatment. 

Lupus (Noli me tangere) , 316 

Causation and description. Varieties : 1. L. erythematosus ; 2. L. 
exedens and Non-exedens ; 3. Pustular lupus. Treatment. 

Keloid (Kelis), 318 

Causation and description. Treatment. 

Xanthoma (ViUUgoidea. Xanthelasma), 319 

Causation and description. Treatment. 

Lichen Kuber, . 320 

Description. Treatment. 

Scleroderma (Scleriasis. Addison's Keloid. Morphoea), . . . 321 
Causation and description. Varieties. Treatment. 

Elephantiasis (Elepjh as. Pachydermia JBarbadoes Leg. E. Arabum), 323 
Causation and description. Treatment. 
Elephantiasis Lymphangiectodes, ....... . 325 

Molluscum Contagiosum, 326 

Causation and description. Treatment. 



CONTENTS. Xvii 

PAGE 

Phthiriasis (Lousiness), . 327 

Causation and description. 1. Pediculus capitis; 2. P. vestimenti; 3. 
P. pubis. Treatment. 

Scabies [Itch), 328 

Causation and description. Acarus scabiei. Treatment. 

Other Skin- affections caused by Animalcules, . . . 331 



Causation and description. Leptus autumnalis. Pulex penetrans. 



Bulama boil. Acarus folliculorum. 

Tinea Tonsurans (Porrigo scutulata. Bingworm), . . . .333 

Causation and description Tricophyton tonsurans. Treatment. 

Tinea Favosa (Favus. Porrigo Favosa and Lupinosa), . . . 335 
Causation and description. Achorion Schdnleinii. Treatment. 

Tinea Versicolor (Pityriasis Versicolor. Chloasma), . . . 337 
Causation and description Microsporon furfur . Treatment. 

Alopecia Areata (A. Circumscripta. Porrigo or Tinea Decalvans), . 337 
Causation and description. Treatment. 

Prurigo, . 340 

Description. Treatment. 

Concluding Eemarks, 311 



III. DISEASES OP THE EE SPIK AT OR Y OEGANS, . 341 
Introductory Eemarks, 341 

Anatomical Relations, . . . . . . . . . . 341 

Larynx and trachea. Lungs. Pleurse. Kegions of chest. 
Pathology of Voice, Respiration, Cough, and Expectoration, .... 343 

1. Voice: feebleness, absence, pitch, quality. 2. Respiration: fre- 
quency, dyspnoea. 3. Cough: varieties. 4. Expectoration: varieties. 

Investigation by Sight and Touch, ........ 349 

1. Larynx and trachea. Laryngoscope. 2. Chest: form, movements, 
fremitus. 

Investigation by Percussion and Auscultation, . . . . . . 353 



1. Percussion. Normal percussion phenomena : a. Kesonance ; b. 
Dulness. Abnormal percussion phenomena, a. Dulness. b. Resonance, 
c. Resistance. 2. Auscultation. The stethoscope. Normal auscultatory 
phenomena: a. Auscultation of the breath; b. Auscultation of the 
voice. Abnormal auscultatory phenomena, a. Tubular or bronchial 
breathing: b. Amphoric, cavernous, or metallic breathing; c. Broncho- 
phony , pectoriloquy , and cegophony ; d. Crepitation, redes ; e. Rhonchus; 



f. Splashing ; g. Amphoric bubble; h. Friction- sounds. 
Detection of Cavities, Consolidated Lung, and Pleural Effusion, . . . 369 
Spirometry, ........ .... 370 

B 



XV111 



CONTENTS. 



PAGE 

Laryngitis, 370 

Causation. Morbid anatomy. Symptoms and progress. 1. Acute 
laryngitis; 2. Chronic laryngitis: aphonia clericorum ; syphilitic and 
tubercular laryngitis. Treatment. 

Tracheitis, . . 371 

Causation. Morbid anatomy. Symptoms. Treatment. 

Bronchitis, 378 

Causation. Morbid anatomy. Symptoms and progress : 1. Acute 
bronchitis; 2. Chronic bronchitis. Treatment. 

Pneumonia, 385 

Causation. Morbid anatomy: lobar pneumonia ; engorgement, red 
and gray hepatization ; lobular pneumonia. Symptoms and progress. 
Treatment. 

Pleurisy (Pleuritis), . 395 

Causation. Morbid anatomy : effusion; suppuration; consequences. 
Symptoms and progress. Treatment. 

Cirrhosis (Chronic Pneumonia. Fibroid Phthisis), .... 405 
Definition. Causation. Morbid anatomy. Symptoms. Treatment. 

Tubercle (Laryngeal and Pulmonary Phthisis. Tubercular Pleurisy), 409 
Causation. Morbid anatomy; 1 Laryngeal tubercle; 2. Pulmo- 
nary tubercle ; 3. Pleural tubercle. Symptoms and progress : chronic ; 
acute. Treatment. 

Syphilitic Disease, 423 

Morbid anatomy : 1. Larynx, trachea, and bronchial tubes ; 2. Lungs. 
Symptoms and progress. Treatment. 

Morbid Growths, 425 

Morbid Growths oj Larynx, ......... 425 

Morbid anatomy : Non-malignant tumors ; malignant tumors. 
Symptoms and progress. Treatment. 

Morbid Growths of Lungs and Pleurce, ....... 426 

Morbid anatomy: Non-malignant tumors; malignant tumors.' 
Symptoms and progress. Treatment. 

Parasitic Disease, . . .. . . ... . . . 430 

Morbid anatomy. Hydatids. Symptoms and progress. Treatment. 

Bronchiectasis (Dilatation of Bronchial Tubes), .... 431 
Causation and morbid anatomy. Varieties. Symptoms and prog- 
ress. Treatment. 

Emphysema, 434 

Causation and morbid anatomy : Interlobular; vesicular. Varieties 
of vesicular. Symptoms and progress. Treatment. 

Congestion, 439 

1. Congestion of larynx, trachea, and bronchial tubes. 2. Congestion 
of lungs. Causation and morbid anatomy. Symptoms. Treatment. 

Dropsy. Hydrothorax, 440 

Causation and morbid anatomy. 1. (Edema of larynx. 2. (Edema 
of lungs ; 3. Pleural dropsy, or Hydrothorax. Symptoms. Treatment. 



CONTENTS. 



xix 



PAGE 

Pulmonary Collapse. Atelectasis, 442 

Causation and morbid anatomy. Varieties. Symptoms and progress. 
Treatment. 

HAEMORRHAGE. PULMONARY APOPLEXY. HAEMOPTYSIS, . . 444 
Causation and morbid anatomy. Varieties. Symptoms and progress. 
Treatment. 

Pneumothorax, 447 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

Paralytic Affections of the Larynx, 448 

1. Paralysis of recurrent laryngeal. 2. Paralysis of superior laryn- 
geal. 3. Complete unilateral paralysis. 4. General paralysis. Treat- 
ment. 

Spasm of the Larynx and Trachea, 450 

1. Larynx. 2. Trachea. Treatment. 

Asthma (Spasm of the Bronchial Tubes), 450 

Definition. Causation. Symptoms and progress. Pathology. Treat- 
ment. 

Hay-Asthma (Hay-Fever), 455 

Definition. Causation. Symptoms and progress. Treatment. 

Autumnal Catarrh, 456 

Causation. Symptoms and progress. Treatment. 



IV.— DISEASES OE THE YASCULAK SYSTEM, . 457 

(1.) Diseases of the Heart, .... 457 

Introductory Kemarks, 457 

Anatomy and Anatomical Relations of Heart, ...... 457 

Dimensions of heart. Kelations of heart to pericardium. Kelations 
of heart to chest-walls and surrounding organs. 
Physiology of Heart, . . . . . . . . . . .460 

Action of heart. Sounds of heart. Pulse: varieties. 

Pathology of Heart, ........... 464 

1. Mechanical and Structural Derangements of Heart, .... 465 



1. Affections external to heart. 2. Affections of muscular walls. 3. 
Affections of valves ; obstructive aortic valve disease ; regurgitant ditto ; 
obstructive mitral valve disease ; regurgitant ditto. 4. Affections of 



contents of heart. 

2. Functional Derangements, . . . . . . . . . 468 

1. Motor derangements. 2. Abnormal sensations. 

3. Effects of Cardiac Derangements on the Walls and Cavities of the Heart, 469 
Effects of Derangements of the Heart on the General Organism, . . . 471 
The Diagnostic Indications of Cardiac Derangements, ..... 472 

1. Alterations in form of precordial region. 2. Alterations in area 
of cardiac dulness. 3. Increased resistance. 4. Pulsation and thrill. 



XX 



CONTENTS. 



PAGE 

5. Abnormal sounds ; pericardial and endocardial murmurs. Venous 
murmurs. 

The Diagnosis, Prognosis, and Treatment cf Cardiac Derangements, . . 475 

1. Pericardial effusion ; pericardial adhesion. Prognosis. Treat- 
ment. 

2. Hypertrophy of heart. Prognosis. Treatment. 

3. Feebleness of heart. Prognosis. Treatment. 

4. Valvular lesions; a. Aortic valve disease; b. Pulmonic valve 
disease; c. Mitral valve disease; d. Tricuspid valve disease. Prog- 
nosis. Treatment. 

Pericarditis, . 483 

Causation. Morbid anatomy. Symptoms and progress. 
Myocarditis, ............ 488 

Causation and morbid anatomy. 
Endocarditis,' ". *. • '. . . . . . . . . 489 

Causation. Morbid anatomy. Symptoms and progress. 
Treatment of Inflammation of the Heart and Pericardium, .... 491 

Morbid Growths and Parasites, 493 

1. Tubercle. 2. Syphilitic gummata. 3. Malignant disease. 4. Fatty 
growth. 5. Parasites: hydatids. Symptoms. Treatment 

Degenerations of the Heart, 495 

Degenerative Changes in Muscular Walls, ....... 495 

Causation and morbid anatomy. 1. Fatty degeneration. 2. Granular 
degeneration. 3. Fibroid degeneration. Symptoms. 

Degenerative Changes in Valves and Endocardium, . . . . 497 

Causation and morbid anatomy. Symptoms. 

Degenerative Changes in Coronary Arteries, . . . . . .4^8 

Treatment, 499 

Aneurism of the Heart, 499 

Causation. Morbid anatomy. Symptoms. 

Rupture of Heart. Effusion of Blood into Pericardium, . 500 

Cau;-ation and morbid anatomy. Symptoms and progress. 

Hydro-Pericardium, 502 

Syncope, . . 502 

Causation. Treatment. 

Palpitation. Graves's Disease {Exophthalmic Goitre), . . . 503 
1. Palpitation. 2. Graves's disease. Definition. Causation. Morbid 
anatomy. Symptoms and progress. Treatment. 

Cardiac Neuralgia. Angina Pectoris, . . . . 506 

Causation. Pathology. Symptoms and progress. Treatment. 

Cyanosis and Malformations, 508 

Cyanosis, ....... . . . . • . . 508 

Causation. Symptoms and progress. Pathology. 

Malformations , . .' . '. ' . . . . . . 510 

Causation and morbid anatomy. Symptoms and progress. 
Treatment, 511 



CONTENTS. XXI 

PAG1S 

(2.) — Diseases of the Arteries, .... 512 

Arteritis, ... . . . . . . • • • 512 

1. Periarteritis. Causation and morbid anatomy. Symptoms. 

2. Endoarteritis. Causation and morbid anatomy. Symptoms. 

Degkneration oe Arteries, ..... 513 
Causation and morbid anatomy. Symptoms. 

Aneurism (Dilatation of Arteries), 515 

Causation. Morbid anatomy. Effects of aneurisms on neighboring 
parts; results. Symptoms and progress. Treatment. 

Thoracic Aneurisms, ........... 520 



Morbid anatomy. Symptoms. 1. Impediment to arterial circula- 
tion. 2. Impediment to venous circulation. 3. Pressure on nerves. 4. 
Pressure on trachea and bronchial tubes. 5. Pressure on oesophagus. 



Treatment. 

Abdominal Aneurisms, .... .525 

Morbid anatomy and symptoms. Treatment. 

(3.) — Diseases of the Veins, .... 526 

Phlebitis, 526 

Causation and morbid anatomy. Symptoms. 

Varix (Dilatation of the Veins), . 527 

Causation. Morbid anatomy. 

(4.)— Arterial and Venous Obstructions, . . . 528 
Thrombosis and Embolism, 528 

Thrombosis, 528 

Causation. Morbid anatomy. In heart ; veins ; arteries. 

Embolism, .......... .' . . 'mn& • • 530 

Causation and morbid anatomy. 

Consequences and Symptoms of Thrombosis and Embolism, .... 532 

Particular Cases of Thrombosis a?id Embolism, ...... 533 



1. Phlegmasia alba dolens. Treatment. 2. Cardiac thrombosis. 3. 
Embolism and thrombosis of the pulmonary artery. 4. Embolism and 
thrombosis of the larger systemic arteries. Treatment. 5. Multiple 
thrombosis or embolism. 



(5.) — Diseases of the Ductless Glands and Blood, . . 536 
Diseases of the Thyroid Body, 536 

Goitre (Bronchocele) . Cretinism, . . . . . . . . .536 

1. Goitre. Causation. Morbid anatomy. Symptoms and progress. 
2. Cretinism. Treatment, 

Diseases of the Spleen, . .543 

Inflammation, . . . . . . . . . . . 543 

Causation. Morbid anatomy. Symptoms. Treatment. 

Congestion, ............. 544 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 

Hypertrophy, ............. 545 



Causation. Morbid anatomy. Symptoms and progress. Treatment. 



xxu 



CONTENTS. 



PAGE 

Tubercle, 546 

Morbid Growths, 546 

Cysts, 547 

Atrophy, ............. 547 

Lardaceons Degeneration, ... ....... 547 

Morbid anatomy. Symptoms. Treatment. 

Diseases of the Suprarenal Capsules, 548 

Tubercle. Addison's Disease [Melasma Addisonii), ..... 548 
Definition. Causation. Morbid anatomy and pathology. Symp- 
toms and progress. Treatment. 

Morbid Growths, 552 

Diseases of the Lymphatics, 552 

Inflammation, ............ 553 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 
Tubercle. Scrofula, 554 

Morbid anatomy. Symptoms and progress. Treatment. 
Morbid Growths. Mediastinal Tumors, ....... 554 

Morbid anatomy. Symptoms and progress. Treatment. 

Leucocythcemia, 557 

Pathology and morbid anatomy. Symptoms and progress. Treatment. 
Obstruction and Dilatation of Lymphatics, ....... 559 

Morbid anatomy and symptoms. Treatment. 

Anosmia. Chlorosis, 560 

Definition. Causation. Symptoms and progress. Pathology. Treat- 
ment. 

Purpura, 563 

Definition. Causation. Symptoms and progress. Varieties. Morbid 
anatomy. Treatment. 

Scurvy (Scorbutus), 565 

Definition. Causation. Symptoms and progress. Morbid anatomy. 
Treatment. 

Chronic Alcoholic Poisoning (Alcoholism). Delirium Tremens, 568 

Delirium Tremens, . . . ' . . 568 

Causation. Symptoms. Pathology and morbid anatomy. Treat- 
ment. 

Chronic Lead-Poisoning (Plumbism). Colic. Dropped Hand, 573 
Causation. Symptoms and progress, i. Lead colic. 2. Nervous 
disorders. Dropped hand. Pathology and morbid anatomy. Treat- 
ment. 

Chronic Mercurial Poisoning (Mercurialism), . . . .578 
Causation. Symptoms and progress. Morbid anatomy. Treatment. 

V. — DISEASES OF THE DIGESTIVE ORGANS, . . 580 
(1.) — Diseases of the Mouth, Fauces, and Adjacent Parts, . 580 
Catarrh, 580 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 

Thrush (Aphtha), . . 584 

Causation and morbid anatomy, Oidium albicans. Symptoms and 
progress. Treatment. 



CONTENTS. 



XX111 



PAGE 

Ulcerative Stomatitis, 586 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

"Noma (Gangrenous Stomatitis). Gangrene of Fauces, . . . 587 
1. Nom,a. Causation. Morbid anatomy. Symptoms and progress. 
2. Gangrene of Fauces. Causation. Symptoms and progress. Treat- 
ment. 

Congestion and Inflammation of the Gums in Dentition, . 589 
Glossitis, 589 

Causation. Symptoms and progress. Treatment. 

Quinsy (Tonsillitis), 591 

Acute Tonsillitis, ........... 591 

Morbid anatomy. Symptoms and progress. Treatment. 
Chronic Tonsillitis, ........... 593 

Symptoms and progress. Treatment. 

Retro-Pharyngeal Abscess, 594 

Causation. Symptoms and progress. Treatment. 

Ozcena, 594 

Causation Symptoms. Treatment. 

Morbid Growths, 595 

1. Tubercle. 2. Syphilis. 3. Malignant tumors. Treatment. 

(2.) — Diseases of the (Esophagus, . . . 596 
Introductory Remarks, 596 

Anatomical Relations, .......... 596 

Inflammation, 597 

Causation. Symptoms. 

Chronic Affections of the (Esophagus, 597 

L Ulcerative Inflammation, ......... 597 

Causation and morbid anatomy. 

2. Morbid Growths, 598 

Morbid anatomy. 

3. Affections implicating (Esophagus from without, ..... 599 

Morbid anatomy. 

4. Dilatation of the (Esophagus, . ........ 599 

Causation and morbid anatomy. 

5. Spasmodic and Paralytic Affections, ....... 600 

Symptoms of Chronic (Esophageal Disease, Dysphagia, .... 600 

Treatment of Chronic (Esophageal Disease, ...... 602 

(3.) — Diseases of Stomach, Intestines, and Peritoneum, . 603 
Introductory Remarks, 603 

Anatomical relations. 

Gastritis, ' . . . 604 

Causation. Morbid anatomy. Symptoms and progress. Varieties. 
Treatment. 



xxiv 



CONTENTS. 



PAGE 

Enteritis, . . . . . 609 

1. Catarrhal Inflammation, ......... 609 

Causation and morbid anatomy. Symptoms and progress. 

2. Pellicular Inflammation, . . . . . . . . . 609 

Causation and morbid anatomy. Symptoms. 

3. Chronic Inflammation, ......... 610 

Causation and morbid anatomy. Symptoms. 

4. Phlegmonous Enteritis, . ... . . ... 610 

Causation and morbid anatomy. Symptoms and progress. 
Treatment, ............ 613 

Ulceration of the Stomach, . . 614 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 

Ulceration of the Bowels, . . . . . . . . 618 

Causation and morbid anatomy. Varieties of ulcer. Symptoms and 
progress. Treatment. 

Duodenal Ulcers, . . . . 624 

Sjmiptoms and progress. Treatment. • 

Perforating Ulcers of the Caecum and Rectum, . . . 624 

Typhlitis. Perityphlitis, ........ . . 625 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

Periproctitis, . . . . . . . . . . . . 627 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

Dysentery, ............ 628 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

Peritonitis, 635 

Causation. Morbid anatomy. Symptoms and progress. Treat- 
ment. 

Cirrhosis of Stomach and Bowels, 642 

Symptoms. 

Tubercle [Abdominal Phthisis), 642 

, Morbid anatomy. 1. Bowels. 2. Peritoneum and abdominal glands. 
Symptoms and progress. 1. Bowels. 2. Peritoneum. Treatment. 

Morbid Growths, ........... 646 

Non- Malignant Growths, . . . . . . . . . . 646 

Malignant Growths, . . ......... 647 

Morbid anatomy. 1. Scirrhus cancer. 2. Colloid. 3. Encephaloid. 

4. Epithelioma. 5. Adenoid cancer. 6. Sarcoma and lymphadenoma. 

Symptoms and progress. 1. Stomach. 2. Bowels. 3. Peritoneum 

and glands. Treatment. 

Parasitic Affections, . 655 

Tapeworms and Cystworms (Cestoda or Tceniada). General Account, . . 655 
Taenia Solium. Taenia Mediocanellata, and Bothriocephalus Latus, . . 656 

1 1. Taenia solium. Cysticercus cellulosse.' 2. Taenia mediocanellata. 

Cysticercus taenise, m. c. 3. Bothriocephalus latus. Symptoms. 

Treatment. 



CONTENTS. XXV 

PAGE 

Taenia Ec'hinococcus. Hydatid, . . . . ... . . 659 

Round Worms (Ncematoda). General Account, . . . . . . 661 

Common Round Worm (Ascaris Lumbricoides), ...... 662 

Symptoms. Treatment. 

Common Threadworm or Seatworm (Oxyuris Vermicularis) , . . . 663 

Symptoms. Treatment. 

Whipworm (Trichocephalus Dispar), ........ 663 

Dochmius Duodenalis (Sclerostoma Duodenale) , ...... 664 

Trichina Spiralis. Trichinosis, ......... 664 

Symptoms and progress. Treatment. 

Degenerative Affections of the Stomach and Bowels, . 667 

Obstruction of the Stomach, 667 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

Obstruction of the Bowels, 670 

1. Constipation, . . . ... . . . . . • . 670 

Causation, morbid anatomy, and symptoms. 

2. Stricture, 671 

Causation and morbid anatomy. Symptoms and progress. 

3. Compression and Traction, . . . . . . . . .673 

Causation and morbid anatomy. Symptoms and progress. 

4. Internal Strangulation, . . . . . . . . . 674 

Causation and morbid anatomy. Symptoms. 

5. Impaction of Foreign Bodies, . . . . . . . . .675 

Causation and morbid anatomy. Symptoms and progress. 

6. Intussusception, ............. 677 

Causation and morbid anatomy. Symptoms and progress. 
Concluding Remarks in reference to Symptoms of Obstruction, . . . 680 

Pain. Vomiting. Constipation. Tumor and shape of belly. Con- 
dition of urine. Duration of life. Statistics. 
Treatme?it, ............. 682 

7. Volvulus. Causation. Symptoms and progress. Treatment, . . . 685 

Ascites {Abdominal Dropsy), 685 



Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

Hemorrhage. Hjematemesis. Meljena, 689 

Definition. Causation. Symptoms and progress. Treatment. 



Dyspepsia (Indigestion), 691 

Causation. Symptoms referable to the stomach ; appetite ; abnormal 
sensation ; flatulence and eructation ; nausea and sickness ; pyrosis. 
Symptoms referable to other organs. Treatment. 

Diarrhoea, . . . ... . . . . . . .699 

Causation. Symptoms and progress. Treatment. Eaw meat in 
treatment. 



xxvi 



CONTENTS. 



PAGE 

(4.) — Diseases oe the Liver, . . . .707 
Introductory Eemarks, 707 

Anatomical Relations, .......... 707 

Physiological Considerations, ......... 708 

Pathological Considerations, . . . . . . . . .710 

Jaundice. 

Hepatitis. Hepatic Abscess. Cirrhosis, 714 



Causation. Morbid anatomy : 1. Congestion and simple inflamma- 
tion ; 2. Inflammation of ducts ; 3. Suppuration ; 4. Chronic inflam- 
mation, cirrhosis. Symptoms and progress : 1. Congestion and simple 
inflammation; 2. Inflammation of ducts; 3. Suppuration; 4. Cir- 



rhosis. Treatment. 

Morbid Growths, 723 

Tubercle, 723 

Syphilis, 724 

Morbid anatomy. Symptoms. Treatment. 

Non- Malignant Growths, . . . . . . . . . 725 

Malignant Growths, ........... 726 

Morbid anatomy. Symptoms and progress. Treatment. 

Parasitic Affections of the Liver, 730 

Hydatids, 730 

Morbid anatomy. Symptoms and progress. Treatment. 

Tatty Liver, 734 ) 

Causation. Morbid anatomy. Symptoms. Treatment. 

Lardaceotjs Liver, 735 

Causation. Morbid anatomy. Symptoms. Treatment. 

Gallstones, 736 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 

Obstruction of the Hepatic Ducts, 741 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 

Jaundice without obvious Obstruction of Ducts, . . .745 

Causation. Morbid anatomy. Symptoms. Treatment. 
Malignant Jaundice ( Yellow Atrophy of the Liver), . . .746 
Causation. Symptoms and progress. Morbid anatomy. Treatment. 

(5.) — Diseases of the Pancreas, .... 749 

Introductory Remarks, . . 749 

Hypercemia and Inflammation, ......... 750 

Morbid Grovrths, . . . . 750 

Calculi, ............. 750 

Obstruction of Pancreatic Ducts, .' . . . . . . . 750 

Symptoms and Treatment, . . . . . . . . . 750 



CONTENTS. 



XXV11 



PAGE 

YI. — DISEASES OF THE GENITO-URINARY ORGANS, . 751 



(1.) — Diseases of the Kidneys, . 751 

Introductory Remarks, 751 

General Physiological and Pathological Considerations, .... 751 

Characters and Composition of the Urine in Health, ..... 752 

Characters and Composition of the Urine in Disease, ..... 754 



Physical characters. Urea. Uric acid and urates. Xanthin. Cystin, 
leucin, and tyrosin. Coloring matters. Odorous matters. Grape sugar. 
Salts: 1. Amorphous phosphate of lime; 2. Crystallized phosphate ; 3. 
Ammoniaco-magnesian phosphate: 4. Oxalate of lime; 5. Carbonate 
of lime. Albumen. Blood. Casts Mucus and pus. Fat. Morbid 
growths. Spermatozoa. Animal and vegetable organisms. Concretions. 
The Specific Consequences of the Retention of Urea and other such matters in 

the Blood, 766 

Thickening and contraction of the smaller bloodvessels. Hyper- 
trophy of the heart Anasarca and other dropsical effusions. Con- 



gestions and haemorrhages. Inflammatory affections. Functional 
consequences. 

The Non-Specific Morbid Phenomena which attend on and characterize Lesions 

of the Kidneys, ............ 769 

Pyelitis, 769 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 

Nephritis. Bright's Disease, 772 

Causation. 

1. Circumscribed and Suppurative Inflammation, ..... 772 

Morbid anatomy. Symptoms. Treatment. 

2. General Acute Inflammation. Acute Bright 's Disease, .... 774 

Morbid anatomy. Symptoms and progress. Treatment. 

3. General Chronic Inflammation. Chronic Bright's Disease, . . . 776 

Morbid anatomy. 1. The smooth white kidney. 2. The fatty kidney. 
3. The contracted granular kidney. 4. The cystic kidney. Symptoms 
and progress. Treatment. 

4. Congestion, . . . . . . • . . . . . . 782 

Morbid anatomy. Symptoms. Treatment. 

Tubercular Disease, 782 

Morbid anatomy. Symptoms and progress. Treatment. 

Syphilitic Disease, 784 

Morbid Growths, 784 

Morbid anatomy. 1. Lymphadenoma. 2. Carcinoma. Symptoms 
and progress. Treatment. 

Parasitic Affections, . . 786 

1. Hydatid cysts. Treatment. 

2. Bilharzia hcematobia. Treatment. 

Lardaceous Degeneration, 787 

Causation. Morbid anatomy. Symptoms and progress. Treatment. 



xxvni 



CONTENTS. 



PAGE 

Urinary Concretions, 788 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

Hydronephrosis and Atrophy, 791 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

Misplaced and Movable or Floating Kidneys, .... 792 

Causation and morbid anatomy. Symptoms. Treatment. 

Chyluria, .793 

Causation and symptoms. Pathology. Treatment. 

HEMATURIA, 795 

Causation and symptoms. Treatment. 

Paroxysmal Hematuria, 796 

Causation. Symptoms and progress. Pathology. Treatment. 

Diabetes {Diabetes Mellitus. Glycosuria), 798 

Causation. Symptoms and progress. Morbid anatomy and pathol- 
ogy. Treatment. 

Diuresis (Diabetes Insipidus), 804 

Causation. Symptoms and progress. Morbid anatomy. Treatment. 

Suppression of Urine (Ischuria Benalis), . . . ... . 805 

1. Functional suppression. 2. Suppression from obstruction. S}nnp- 
toms and progress. Treatment. 

(2.) — Diseases of the Pelyic Organs, . . . 807 
Diseases of the Urinary Bladder, 807 

1. Inflammation, ........... 807 

2. Tubercle, 808 

3. Morbid Growths, 808 

4. Dilatation, . . 808 

Symptoms and treatment. 

Diseases of the Uterus, Fallopian Tubes, and Ovaries, . . 809 

Metritis and Oophoritis, .......... 809 

Causation and morbid anatomy. Symptoms. 

Morbid Growths and Cysts, . . . . . . . . .810 

Tubercle. Symptoms. Myomata. Symptoms. Cystic tumors Causa- 
tion and morbid anatomy. Dilatation of the cavity of the uterus. Di- 
latation of the Fallopian tubes. Ovarian cysts. Symptoms and prog- 
ress. Treatment. Malignant disease. Symptoms. 

Diseases of the Pelvic Peritoneum and Connective Tissue, . 815 

VII — DISEASES OF THE OKGAKS OF LOCOMOTION, . 816 

Eheumatism (Bheumatic Fever), 816 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Pathology. Treatment. 

i 



CONTENTS. 



xxix 



PAGE 

Rheumatoid Arthritis (Chronic Bheumatic Arthritis), . . . 825 
Definition. Causation. Morbid anatomy. Symptoms and progress. 
Pathology. Treatment. 

Gout (Podagra), .828 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Pathology. Treatment. 

Rickets (Bachitis), 837 

Definition. Causation. Morbid anatomy and pathology. Symptoms 
and progress. Treatment. 

Mollities Ossium (Osteo-malacia), 844 

Definition and causation. Morbid anatomy and pathology. Symp- 
toms and progress. Treatment. 

Pseudo-Hypertrophic Paralysis, 846 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Pathology. Treatment. 

VIII. — DISEASES OF THE NERVOUS SYSTEM, . 848 
Introductory Remarks, 848 

Anatomy and Physiology, ... . . . . . . . 848 

Membranes of brain and cord. Ventricles of brain and cord. Cere- 
bral hemispheres: 1. Sulci ; 2. Convolutions; 3. Functions of surface of 
brain. Ganglia at base of brain. Cerebellum and its peduncles. Spinal 
cord. Medulla oblongata. Cerebro-spinal nerves. Motor and sensory 
functions. Sympathetic system. Arteries of brain. 

Pathology, 863 

1. Motor Paralysis. Paresis, ......... 864 

Cerebral paralysis. 1. General paralysis. 2. Hemiplegia. Bulbar 
paralysis. Spinal paralysis — paraplegia. Nerve paralysis. Condition 
of muscles in motor paralysis. 1. Tone. 2. Contractility and irrita- 
bility. 3. Electro-sensibility. 4. Nutrition. 5. Reflex action. 

2. Anaesthesia, ... . . ... . . . . . . 870 

Cerebral anaesthesia. 1. General anaesthesia. 2. Hemianesthesia. 
Bulbar anaesthesia. Spinal anaesthesia. Nerve anaesthesia. 

3. Convulsions. Spasms, .... ...... 872 

4. Hypercesthesia. Dysesthesia, . . . . 874 

5. Influence of Nervous Diseases over Nutritive Processes, .... 875 

Sympathetic system. Cerebro-spinal system. 1. Muscles. 2. Joints 
and bones. 3. Skin ; bed-sores. 4. Viscera. Eecapitulation. 

6. Ascending , Descending, and Collateral Lesions, ..... 881 

7. Central and Reflex Consequences of Lesions of Nerves, .... 882 

8. Headache, . . .... . . . . . 883 

9. Vertigo, . . . . . . . ' 884 

10. Impairment or Loss of Power of Speech (Aphasia. Aphernia. Amnesia), 885 

Varieties. 

11. Mental and Emotional Disturbances, . . ... . . 890 

Inflammation of the Cerebral and Spinal Dura Mater. 

Pachymeningitis, . . 891 

Causation. Morbid anatomy: 1. Cerebral dura mater; 2. Theca 
vertebralis ; 3. Pachymeningitis. Symptoms and progress; 1. Acute 



XXX 



CONTENTS. 



PAGE 

inflammation of the cerebral dura mater ; 2. Pachymeningitis of the 
cerebral dura mater; 3. Acute general inflammation of the theca ver- 
tebralis ; 4. Caries of the vertebraa ; 5. Cervical pachymeningitis. 
Treatment. 

Cerebral and Spinal Meningitis. Tubercular Meningitis. 

(Acute Hydrocephalus), 900 

Causation. Morbid anatomy: 1. Cerebral meningitis ; 2. Tubercu- 
lar meningitis ; 3. Spinal meningitis. Symptoms and progress : 1. 
Cerebral meningitis ; 2. Spinal meningitis. Treatment. 

Encephalitis and Myelitis, 910 

Inflammation and Suppuration of the Substance of the Brain and Cord, . 910 
Causation. Morbid anatomy : 1. Encephalitis; 2. Myelitis. Symp- 
toms and progress : 1. Encephalitis; 2. Myelitis. Treatment. 

Sclerosis ( Chronic Inflammation), . .' 917 

Infantile Spinal Paralysis (Infantile Paralysis) , ...... 918 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

Note in Eeference to Earadic and Electric Contractility, . 920 
Adult Spinal Pa?*alysis, .......... 922 

General Spinal Paralysis, .......... 923 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

Progressive Muscular Atrophy (Wasting Palsy), ..... 925 
Definition Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

Lateral Sclerosis, ........... 928 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

Tabes Dorsalis [Locomotor Ataxy), ........ 932 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

Glosso-labio-laryngeal Palsy, ......... 938 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

Disseminated Sclerosis (Multiple Sclerosis), ...... 941 

Definition. Causation. Morbid anatomy. Symptoms and progress : 
1. Ehythmical tremors ; 2. Affections of the eyes ; 3. Defect of speech ; 
4. Vertigo; 5. Paresis of limbs ; 6. Contraction of limbs ; 7. Expression 
and mental condition. Stages. Treatment. 

Paralysis Agitans, 948 

Definition. Causation. Morbid anatomy. Symptoms and progress. 
Treatment. 

Morbid Growths. Aneurisms. Entozoa, 952 

Morbid anatomy : 1. Tubercle; 2. Syphilis; 3. Neoplasms; (a) myx- 
oma; (b) glioma; (c) sarcoma; (d) carcinoma ; 4. Entozoa; (a) cysti- 
cerci ; (b) hydatids; 5. Aneurisms. Symptoms and progress : 1. Brain. 
Vertigo ; headache ; slowness of pulse ; hemiplegia ; local paralysis ; 
local affection of sensory nerves; intellectual and emotional disorders; 



CONTENTS. 



xxxi 



PAGE 

obstruction of venous sinuses ; 2. Spinal cord, (a) In substance of 
cord ; (b) in meninges ; (c) in tissues external to meninges. Treatment. 

Cerebral and Spinal Haemorrhage (Apoplexy), .... 963 
Causation. Morbid anatomy ; haemorrhage on surface ; haemorrhage 
into the brain, into the cord. Symptoms and progress ; in cerebral 
haemorrhage ; in spinal haemorrhage. Treatment. 

Obstruction of Cerebral Arteries (Thrombosis. Embolism. 

Softening), 973 

Causation and morbid anatomy. Symptoms and progress. Treat- 
ment. 

Hydrocephalus and Hydrorhachis. (Cerebral and Spinal Dropsy), 978 
Causation and morbid anatomy. Hydromeningocele ; hydrencepha- 
locele. Spina bifida. Chronic hydrocephalus. Internal hydrorhachis. 



Symptoms and progress. Treatment. 

Chorea (St Vitus' s Dance), 984 

Definition. Causation. Symptoms and progress. Morbid anatomy 
and pathology. Treatment. 

Epilepsy. Eclampsia. Infantile Convulsions, . . .992 

Epilepsy (Morbus comitialis vel sacer), ....... 992 

Definition. Causation. Symptoms and progress. Description of 



epilepsia gravior or the haut mal. Description of abortive fit and of the 
petit mal or epileptic vertigo. The status epilepticus. Kecurrence of 
fits. Causes determining the occurrence of fits in epileptics. Condition 
of epileptics in intervals between the attacks Epileptic mania. Di- 
agnosis. Feigned epilepsy. Morbid anatomy and pathology. Treat- 



ment. 

Eclampsia, ............ 1004 

Definition and causation. Symptoms and progress. Treatment. 

Infantile Convulsions, .......... 1005 

Definition and causation. Symptoms and progress. Treatment. 

Hysteria, . . . . 1007 



Definition. Causation. Symptoms and progress ; convulsions ; hy- 
peraesthesia ; anaesthesia; convulsive movements ; paralytic conditions ; 
affections of the larynx and air-passages, of the alimentary canal, of the 
urinary organs, of the reproductive system, of the spine, joints, and 
mammae. Spinal irritation. Diagnosis. Pathology. Treatment. 

Catalepsy, Ecstasy, and other Conditions allied to Hysteria, 1018 



1. Rhythmical and other Methodical Movements, ..... 1019 

2. Catalepsy, 1019 

3. Ecstasy, 1019 

4. Double-consciousness, .......... 1020 

Treatment, ' . . 1020 

Tetanus (Trismus. Lockjaw), . 1020 

Definition. Causation. Symptoms and progress. Trismus or lock- 
jaw. Opisthotonos. Emprosthotonos. Pleurosthotonos. Diagnosis. 
Morbid anatomy. Treatment. 



xxxii 



CONTENTS — LIST OF DIAGRAMS — ERRATA. 



PAGE 

Congestion. Anemia. Sunstroke, 1025 

Congestion and Ancemia, ..... . . . . . 1025 

Symptoms : 1. Delirium Tremens. 2. Insanity. 3. Eclampsia. 
4. Apoplexy and Paralysis. Treatment. 
Sunstroke (Coup de Soleil. Calenture. Insolatio), . . . . . 1028 

Definition. Causation. Symptoms and progress. Morbid anatomy 
and pathology. Treatment. 

Megrim (Migraine. Hemicrania. Sick headache), .... 1030 
Definition. Causation. Symptoms and progress. Pathology. 
Treatment. 

Meniere's Disease (Aural Vertigo), . 1034 

Definition. Causation and pathology. Symptoms and progress. 
Treatment. 

Local Paralysis, , . 1036 

Paralysis of the Third, Fourth, and Sixth, or Oculo-Motor Nerves, . . 1036 

Causation. Symptoms and diagnosis. Treatment. 
Paralysis of the Fifth Nerve, 1040 

Causation. Symptoms and diagnosis. Treatment. 
Paralysis of the Portio Dura (Bell's Paralysis), . . . . . 1042 

Causation. Symptoms and diagnosis. Treatment. 
Paralysis of the Spinal Nerves, ........ 1045 

Causation. Symptoms and diagnosis: 1. Deltoid rheumatism ; 2. 
Paralysis of radial or musculo-spiral nerve. Treatment. 

Local Functional Spasm and Paralysis. Writer's Cramp, 

Wry-Neck, Etc., . 1047 

Definition. Causation. S}'mptoms and diagnosis: 1. Writer's 
cramp ; 2. Spasmodic wry-neck, etc. Pathology. Treatment. 

Neuralgia. Tic Douloureux, . 1050 

Definition. Causation. Symptoms and progress; 1. Tic doulou- 
reux. 2. Sciatica, and other forms. Treatment. 

Addendum to Diseases of the Yascular System, . . . 1056 

Pulsation of the liver in heart disease. 
Index. . 1057 



LIST OF DIAGRAMS. 

Fig. 1. Pulse Trace, . . . . 462 

« 2. Pulse Trace, . " . . . . . . . ■ . .463 

" 3. Horizontal Section of Eye, showing Axes or Kotation, . 1037 
" 4. Anterior View of Eyeball, showing the Direction oe the 

Movements effected by its several Muscles, . . . 1038 
" 5, 6, 7, 8, 9, 10. Diagrams showing Relations of True to False 

Image in Different Varieties- of Squint, .... 1040 



. Errata. 

Page 560, line I, for teleangiectodes read lymphangiectodes. 
Page 568, line 9, for acne tuberculatum read acne tuberculata. 



THE 



PRACTICE OF MEDICINE. 



PART I. 

GENERAL PATHOLOGY. 



THE DEFINITION OF DISEASE. 

Pathology, or the physiology of disease, is the science of life, under 
morbid or abnormal conditions. This science, and the arts of apply- 
ing it in the detection and in the alleviation or cure of disease, and 
in its prevention, form the subject-matter of works on medicine and 
surgery. 

The question, then, "What is disease?" arises naturally on the very 
threshold of a treatise on the practice of medicine. But although 
every physician, doubtless, has a notion, sufficiently clear for the prac- 
tical purposes of his art, of what is implied in the word, the question 
before us is one which by no means admits of a ready and explicit 
answer. Disease, in some 'at least of its forms, has been regarded by 
many persons, and is probably still regarded by some, as a real thing 
or entity. This view implies that it can either be cut out by the anat- 
omist, or extracted by the chemist, or excreted by the patient himself, 
or in some other way separated from his body so as to become capable 
of independent existence and recognition ; and might be supported, on 
the one hand, by reference to the discharge of an intestinal worm or 
the removal of a vesical calculus, and on the other hand by reference 
to a patch of psoriasis, an epitheliomatous tumor, a malformed heart, 
or indeed almost any other so-called " local " disease. A little thought, 
however, will satisfy the mind that the intestinal worm or the calculus 
is of itself the mere cause of disease, and not disease ; and that the 
patch of psoriasis, the epitheliomatous tumor, or the malformed heart, 
is simply a diseased fragment of the body, and no more the disease 
itself than the patient who is suffering from scarlet fever or syphilis is 
the actual embodiment of either of these latter two affections. But 



18 



THE DEFINITION OF DISEASE. 



indeed the opinion that disease is an entity has now been abandoned by 
all thoughtful physicians. Another view of disease is that it consists 
in any deviation from the healthy state, or (at greater length) in any 
condition of the entire system or of any part of it attended with im- 
pairment or derangement of structure or of function, or of both, and 
tending to render life uneasy, burdensome, or useless, or to shorten it. 
It would be difficult, perhaps, to dispute the accuracy of this definition 
so far as it goes; at the same time it is obvious that we gain nothing 
by it unless we have previously agreed upon a definition of health ; 
and in fact, by accepting it, we simply shirk the difficulty which we 
pretend to solve. 

If we consider attentively the various morbid processes and symp- 
toms which separately or in combination indicate the presence of dis- 
ease, and trace them in each case backwards to their origin, we cannot 
avoid the conclusion that that origin is some definite or peculiar cause, 
either innate in the system or acting on it from without, and deter- 
mining according to its nature and its mode of operation the character 
and the grouping of the morbid phenomena which ensue; in other 
words, that the biography of every disease comprises some special 
cause, and certain resultant phenomena (vital, chemical, or mechanical) 
which are, or which produce, the symptoms and signs by which we 
recognize its presence. Let us test the accuracy of this view of disease, 
and its significance in helping us to define disease, by reference to a 
few examples. 

A patient is suffering from scabies or tinea tonsurans. In the one 
case his epidermis is traversed by a lowly form of vegetable growth, 
and the seats of this growth are indicated by rings of superficial inflam- 
mation, by desquamation, and the destruction of hair; in the other 
case, his epidermis is undermined by the burrows of swarming acari, 
which produce local irritation with intolerable itching, and involve the 
formation of vesicles and pustules. Now in each of these examples we 
have an obvious cause, and certain resultant phenomena — the former 
being the parasite, the latter certain localized inflammatory processes 
which are fairly characteristic. We have the two factors, the cause and 
its consequences. We have also the disease. But where is it, and 
what is it ? Is the disease the parasite, the presence of which is essen- 
tial in order that the disease should present its specific characters? Is 
it the inflammation which the presence of the parasite evokes? The 
answer to both of these questions must surely be in the negative. The 
parasite away from the body in which it resides, or apart from the 
irritation which it causes, is simply a living member of the animal or 
vegetable kingdom ; the local inflammation, dissociated from its cause, 
is inflammation, if you will, but neither scabies nor ringworm. Ob- 
viously then, as applied to such cases as these, the word disease includes 
(if it have any real meaning), both the special cause of the disease and 
the pathological consequences of the operation of that cause. 

Again, a person who has never had scarlet fever inhales the particles, 
or the contagium, which is the specific cause of scarlet fever, and forth- 
with becomes the subject of that disease. The contagium multiplies 
within his system, and presently a characteristic rash overspreads his 



THE DEFINITION OF DISEASE. 



19 



surface, his tonsils and probably his kidneys become inflamed ; and, in 
association with these conditions, there is profound disturbance of his 
nutritive processes, indicated by heightened temperature, increased for- 
mation of urea, and many so-called " functional derangements." Now 
here again we have the contagium, which is the cause of the disease, 
and the various morbid processes which result from its operation. But 
where is the disease? What is meant by the term "scarlet fever?" 
The specific contagious particle of scarlet fever gives scarlet fever, 
exactly as the acarus scabiei gives itch, or the trichophyton tonsurans 
gives ringworm : a group of mutually-related phenomena spring up 
as invariably in obedience to their cause in the former case as in the 
latter cases. But the contagium of scarlet fever may, as we know, gain 
an entrance into the living body, and yet be inoperative there ; and, 
on the other hand, we find that several of the more prominent phenom- 
ena which form a part of scarlet fever, or symptoms which seem to us 
identical with the corresponding symptoms of scarlet fever, are occa- 
sionally combined in persons who are certainly not suffering from this 
exanthem. Yet, obviously, in neither of these cases is scarlet fever 
present. In the former case, the host remains healthy ; in the latter 
case, the disease, though presenting some points of superficial resem- 
blance to scarlet fever, is potentially and essentially distinct from it. 
Here also, then, it is obvious that, when we speak of the disease, we 
include in our meaning, not only the symptoms by which we recognize 
its presence, but the cause upon which those symptoms depend. 

Let us take another case. A man is exposed to cold and wet, and 
shortly afterwards one of his joints becomes swollen and painful ; febrile 
symptoms, attended with abundant sour-smelling perspirations, manifest 
themselves; presently inflammation attacks other joints; perhaps too 
the heart becomes implicated. We have here a lot of symptoms which 
collectively teach us that the patient is suffering from the disease known 
as acute rheumatism. But what is acute rheumatism? Mere inflam- 
mation of a joint, such as that which results from a sprain, does not 
constitute it; nor even successive or simultaneous attacks of inflam- 
mation of several joints ; for if so, both gout and pyemia should be 
embraced within its meaning. Still less are high temperature and pro- 
fuse perspirations rheumatism ; still less acute heart disease, or any of 
its various other inflammatory complications. Further, the merely for- 
tuitous concurrence of most or even all of the symptoms which have 
just been enumerated would still not render the case in which they oc- 
curred a case of rheumatism. Something more is required for that 
purpose : a something which shall link all the symptoms together into 
a common brotherhood, a something which shall constitute their com- 
mon parentage, a cause from which all shall have directly or indirectly 
sprung, and which shall have impressed upon them their separate and 
collective peculiarities. Whether that cause consist in some chemical 
or other change which has been produced in the blood flowing through 
the part exposed to cold, or in some similar change induced through 
the agency of the sympathetic nerves in the vessels and connective 
tissue of the joints which become inflamed, whether the precise nature 
of the cause is known or altogether unknown, is immaterial for our 



20 



THE DEFINITION OF DISEASE. 



argument. In this case, as in the other cases which have been quoted, 
a cause is or has been undoubtedly in operation ; and independently of 
it the disease "rheumatism" has no existence. 

The relation between cause and effect in disease, and the necessity 
for not overlooking the cause as an essential part of the disease, are 
nowhere more obvious than when we have to do with affections in 
which the cause is tangible, or admits of being weighed, measured, or 
otherwise tested or examined ; as, for example, where mechanical im- 
pediments occur in the course of the bowel, urethra, ducts of glands, 
and other tubular organs; or where poisons have been received into 
the system and act chemically upon the stomach, or on distant organs 
in which they are deposited, or through which they circulate ; or where 
finally, certain results follow from excess, deficiency, or unwholesome- 
ness of diet. 

Now, in every one of the examples which has been hitherto adduced, 
it is beyond dispute that neither the collective morbid phenomena or 
symptoms which indicate the presence of disease, taken by themselves, 
nor the morbid cause on which these phenomena depend, taken by itself, 
constitute a disease; that, alone, they are simple factors of disease; 
and that our conception of a disease is fulfilled only when the cause 
and its results are welded, as it were, mentally into one common whole. 
And hence, if these views are generally true, disease may be defined 
as a complex of some deleterious agency acting on the body, and of the 
phenomena (actual or potential) due to the operation of that agency. 

Regarding it, not as a matter of idle curiosity, but as one of funda- 
mental importance for a clear appreciation of the aims and limits of 
diagnosis and treatment, that we should have a distinct comprehension 
of what we mean by disease, we shall pursue the question yet a little 
further, mainly with the object of determining how far the word dis- 
ease is properly applicable (as it often is applied in practice) to mere 
symptoms or secondary phenomena or incidents of disease. 

All diseases involve, some in a greater some in a lesser degree, cer- 
tain groups of pathological consequences immediately traceable to their 
respective morbid causes; but these primary pathological consequences 
themselves tend to evoke others^ these again a tertiary series, and so on 
continuously. Thus a person with carcinoma of the bowel may have 
as a consequence stricture, or perforation, or secondary involvement of 
the glands occupying the retroperitoneal tissue and the gastro-hepatic 
omentum, or that form of cachexia which cancerous disease so frequently 
induces ; and as a consequence of these several secondary morbid con- 
ditions various other phenomena, such as enteritis or peritonitis, jaun- 
dice, ascites, melsena, thrombosis, or anasarca. 

Now all these phenomena, and many others, are obviously integral 
portions of the carcinomatous affection from which the patient is suffer- 
ing, and all of them may be regarded as symptoms or secondary phe- 
nomena of that affection ; but many of them are not unfrequently looked 
upon also as quasi-independent diseases, and treated as such. There 
is no doubt that they are in truth secondary phenomena or symptoms, 
and there is equally no doubt that they are not diseases. They are, 
however, clearly elements of disease ; and inasmuch as each one of them 



THE AETIOLOGY OF DISEASE. 



21 



arises oat' of some immediately antecedent abnormal condition which 
is its direct cause, they do obviously enough, in association with their 
respective causes, fall severally within oar definition of disease. Hence 
the affection which has been selected for illustration, and it may be 
added all other primary diseases, may be considered to comprise or 
involve a n amber of what, regarded from one point of view, are symp- 
toms or secondary phenomena, regarded from another point of view, 
are component parts or factors of secondary or subordinate diseases, 
issuing in collateral lines of descent from a common ancestral cause. 



THE AETIOLOGY OF DISEASE. 

The causes of disease have been divided by authors into three classes, 
namely, the predisposing, the exciting, and the proximate ; the first class 
comprising those conditions which so modify the health of the patient 
as to render him apt, or predispose him, to contract the disease, to the 
specific influence of which he happens to be exposed ; the second, those 
causes which immediately impart or excite disease, and give it its spe- 
cific character; the third, those morbid processes which the action of 
the exciting cause calls into play, and to which the symptoms of disease 
are supposed to be directly due. The proximate cause indeed is often 
stated, though erroneously, to be the disease itself. We will illustrate 
the above distinctions by an example. A woman, who has frequently 
been exposed to the contagion of scarlet fever without taking the disease, 
becomes at the period of childbirth again exposed, and now suffers 
from a virulent attack. Here, parturition (which, as we know, renders 
women peculiarly susceptible of the contagious fevers) is the predispos- 
ing cause, the scarlatinal contagium is the exciting cause, and the in- 
flammatory processes going on in the skin, tonsils, and elsewhere the 
proximate cause of most of the symptoms which the patient manifests. 
But the exciting cause of the scarlet fever is obviously the proximate 
cause of that disease, and the proximate causes of its several secondary 
phenomena are just as obviously their exciting causes. 

The distinction between the exciting cause and the proximate cause 
is thus purely artificial. That between the predisposing cause and the 
exciting cause, on the other hand, is in general well marked ; and 
doubtless if we had an accurate knowledge of the causation of disease, 
the universality of the truth which underlies these terms would be quite 
beyond dispute. As it is, however, doubts or difficulties as to their 
meaning and application are apt to present themselves. 

An example will explain our meaning. A man who has been suffer- 
ing from privation, is exposed to malarial influence, and contracts ague. 
In this case, clearly enough, privation is the predisposing cause, malaria 
the exciting cause. But after a time the ague leaves him, and he is 
apparently restored to health, and he continues well until perchance 
from exposure to the weather in some non-malarious district he catches 



22 



THE JETIOLOGY OF DISEASE. 



cold, and straightway experiences another attack of ague. Now which 
in the latter case should be regarded as the exciting cause ? The answer 
will probably be, "exposure to cold and wet," an answer which neces- 
sarily implies that on this occasion malaria is the predisposing cause. 
Yet, notwithstanding, malaria is equally in both cases the specific cause 
of the disease, and acts (as we have no reason to doubt) in both cases 
in a precisely similar manner. 

On the whole, however, we mean by exciting cause the specific cause, 
or element, in disease, that cause (the contagium of an exanthem, the 
virus of rabies, the parasite of a tinea) which stamps its individuality 
on the group of morbid processes which ensue, and constitutes with 
them a definite or specific disease; and by predisposing causes we mean 
those general, non-specific conditions which by their influence so modify 
the health of the system, or of parts of it, as to render them (so to speak) 
a specially suitable soil for the growth of certain diseases, supposing 
their germs happen to become implanted therein. 

Predisposing Causes of Disease. 

We shall not pretend to discuss the subject of predisposing causes at 
any length, although it is one of great importance, especially in relation 
to preventive medicine; but shall content ourselves with enumerating 
and considering briefly some of the more important and more gener- 
ally recognized amongst them. 

1. The influence of age is very striking. The period of growth and 
development, commencing with birth and terminating with the attain- 
ment of maturity, and comprising the important physiological epochs 
of the first dentition, the second dentition and the unfolding of the 
sexual system, is attended not only with a general aptitude for diseases 
which have a special connection with the physiological processes (general 
or special) which are going on then, but is liable also for other less ob- 
vious reasons to the attacks of various maladies of other kinds. In 
early infancy a remarkable tendency exists to disturbances of the ali- 
mentary canal, and to these causes a very large proportion of infantile 
mortality is due. Again at this time, and especially during the period 
of the first dentition, epileptiform convulsions are of peculiar frequency. 
Rickets is a disease which can only manifest itself during the period 
of growth of the osseous system, and does in fact occur during the first 
few years of childhood. It is about this time also that pseudohyper- 
trophic paralysis is most commonly met with. True asthma generally 
comes on in childhood, and not unfrequently disappears before ma- 
turity is reached. Chorea in large proportion affects young persons 
between the ages of 8 or 9 and 15 or 16; and epilepsy, when not im- 
mediately traceable to infantile convulsions, commences very frequently 
indeed about the same time. Acute rheumatism again and scrofulous 
diseases are disproportionately common in young persons. It may be 
added that some parasites are peculiarly prone to affect children; and 
amongst these threadworms probably, and the trichophyton tonsurans 
certainly. Few special liabilities to disease mark the period of ma- 
turity, excepting such as are connected with difference of sex, or arise 



PREDISPOSING CAUSES OF DISEASES. 



23 



out of habits of life and other circumstances which have only an acci- 
dental connection with age. But as the decline of life approaches, and 
during its continuance, many disorders, and mainly such as are con- 
nected with the decay and degeneration of tissues and organs, manifest 
themselves. Thus the central nervous system becomes affected, and 
feebleness of mind or fatuity and paralysis supervene; or the heart 
undergoes morbid changes, and dropsies and haemorrhages result ; or 
the vessels become weakened, and aneurisms and ruptures with extrava- 
sations of blood occur; or the stomach, or the liver, or the kidneys or 
other organs get implicated and cease to act efficiently. Gout, too, 
should be probably included among the proclivities of advancing years. 

2. The differences in the organization of the sexes necessitate, of course, 
differences as regards some of the diseases to which they are respec- 
tively liable. It need scarcely be pointed out that in one sex we meet 
with disorders connected with the uterus and ovaries, disorders of men- 
struation, pregnancy, and lactation ; in the other sex affections which 
are peculiar to the male organs of generation. Bnt besides these nec- 
essary differences, there are others which are far more difficult to ex- 
plain and yet are nearly as constant. Thus chlorosis and hysteria, and 
nervous disorders related to hysteria, are the almost exclusive heritage 
of females. And again, certain other affections which occur in both 
sexes, are yet, for no sufficient reason, so far as we can see, far more 
frequent in the one than in the other. Thus, erythema nodosum, and 
exophthalmic goitre, and goitre itself, are all far more common in 
females than in males. It is possible, of course, that some of these 
latter differences may not be due to the influence of sex alone. 

3. Personal "peculiarities •, born with the individual, and often heredi- 
tary, have an important influence over the relative liability of persons 
to disease. We know how closely children resemble one or other of 
their parents, not only in the general configuration of the body, but in 
features, expression, complexion, and in mental attributes. We know 
also how trivial peculiarities in the form of some feature, in the tone 
of the voice, in the quality of the laugh, small oddities of manner or 
of gesture, become perpetuated in families. It is not surprising, there- 
fore, that malformations and other morbid conditions and tendencies 
to disease should be transmitted also. It is important, however, to 
note : first, that such inherited peculiarities and tendencies not unfre- 
quently skip a generation, or appear as it were sporadically in families, 
so that, while out of a family of brothers and sisters some are affected 
and others escape, the affected and unaffected procreate indifferently 
healthy and unhealthy offspring ; second, that the inherited tendency 
to disease does not in all cases manifest itself in an exact reproduction 
of the morbid peculiarity of the parent; and third, that undoubtedly 
in many cases peculiarities of constitution and special proclivities to 
disease appear altogether de novo. In some instances the morbid con- 
dition is developed, or appears, in foetal life ; in other instances the 
child is born healthy, but with a tendency to disease, which becomes 
realized at some later period. As examples of the former case may be 
enumerated congenital malformations, idiocy, nsevi. Examples of the 
latter case are far more common and far more important for the physician, 



21 



THE ETIOLOGY OF DISEASE. 



and need, therefore, a little more detailed consideration. Certain func- 
tional nervous disorders, such as insanity, epilepsy, hysteria, asthma, 
neuralgia, undoubtedly run in families, and are apt in some degree to 
alternate, so that a parent suffering from one of them may beget chil- 
dren in whom one or other of the remaining members of the group 
replace as it were the particular parental malady. Again, gout, tuber- 
culosis, carcinoma, and other forms of growths, all manifest a tendency 
to hereditariness. So do many varieties of skin disease, such as ich- 
thyosis, psoriasis, and acne. Degenerative affections, and especially 
those which are characterized by fatty or calcareous changes, have also 
a tendency to repeat themselves. Thus, we know that in some families 
the members are apt to be cut off prematurely by extravasations of 
blood into the brain, due to such degeneration of the cerebral arteries ; 
that in other families the heart appears to be the selective seat of such 
changes. Lastly, among inherited or personal peculiarities, we must 
not forget certain idiosyncrasies characterized by special aptitude to 
become affected by agencies which to most persons are innocuous, or to 
remain unaffected by conditions which are generally inimical. The 
influence of the emanations from fresh hay in producing hay-asthma, 
of the smell of many flowers in creating nausea, the specially poisonous 
effects which even the smallest doses of mercury, opium, or other drugs, 
and which also certain forms of food (even such wholesome meat as 
mutton) have upon certain individuals, the unhappy tendency which 
some persons seem to have to contract all the catching diseases to which 
they are exposed, and even to take the same one over and over again, 
and the remarkable way in which other persons seem always to escape, 
are common examples of the peculiarities referred to. 

4. Occupation, habits of life, quality of food or drink, over-indulgence, 
privation, and even abstinence, are all of them potent agents in modify- 
ing the constitution, and rendering the frame susceptible of disease. 
We may quote in exemplification of this statement the acquired pro- 
clivity of compositors to tubercular phthisis; that of persons who lead 
sedentary lives to suffer from indigestion and constipation, and the 
effects of accumulated fat ; and that of persons who habitually eat or 
drink to excess to become gouty, and to suffer from renal and hepatic 
disorders. It would be easy to multiply examples of the influence of 
these and like causes in the production of disease, and especially to 
adduce illustrations which might appear far more striking than any of 
the few given above, such as the occurrence in miners and others of 
special forms of lung disease, in painters of dropped hand, in drinkers 
of cirrhosis of the liver, delirium tremens, and so on. But it is obvious 
that we have here examples not of any mere predisposition which has 
been gradually acquired, but of the direct and specific influence of cer- 
tain exciting causes to which the sufferers have been exposed. 

5. The effects of previous disease in modifying the tendency to sub- 
sequent attacks of disease are in many cases quite remarkable. In the 
exanthemata and allied affections an attack of any one is in a very high 
degree protective against subsequent attacks of the same malady. On 
the other hand, many inflammations, when once they have appeared, 
tend to repeat themselves. Thus we find many persons who have once 



PREDISPOSING CAUSES OP DISEASE. 



25 



had erysipelas of the face retain a liability to attacks of the same malady 
throughout the remainder of their lives. So it is with rheumatism, 
pneumonia, bronchitis, tonsillitis, catarrh, renal inflammation, inter- 
mittent hematuria, and the like. And indeed one of the most difficult 
practical problems with which physicians have to deal is that of the 
counteraction of such acquired tendencies. But there are many disor- 
ders which engender a liability, not to their own recurrence, but to the 
attacks of other diseases. Thus both scarlet fever and gonorrhoea are 
curiously apt to be followed by attacks of acute rheumatism. Tuber- 
culosis is generally believed to follow frequently on enteric fever and 
on small-pox, and scrofulous enlargement of the cervical glands on 
mumps. And chorea may certainly be regarded as a sequela of both 
acute rheumatism and scarlet fever. To these latter examples may be 
added the fact, which seems quite beyond dispute, that organs and parts 
which have been the seats of repeated or continuous attacks of inflam- 
mation, and have in consequence undergone structural changes, and so 
also pigmentary nsevi, prove often the selective sites for the primary 
development of sarcomatous and other kinds of malignant growths. 

It may be convenient to refer here to the special predispositions to 
disease of different organs and tissues. A very little acquaintance with 
pathology is sufficient to prove that the different parts of the system are 
not all equally liable, nor liable in proportion to their respective bulks, 
or vascular supply, or importance, to the same forms of disease. We 
need scarcely, perhaps, point to the facts, that each one of the specific 
infectious fevers involves in its progress certain organs, altogether dis- 
proportionately to other organs, if not to the entire exclusion of some ; 
that parasites, whether vegetable or animal, limit their attacks to cer- 
tain parts exclusively, or at all events mainly, such as the skin, the 
muscular system, the liver, and the intestinal canal ; and that the in- 
flammations of rheumatism and of gout are especially wont to seize on 
the ligaments and other soft parts about joints. Tumors, according to 
their characters, are prone to originate in different tissues; thus tuber- 
cle, which is so wide in its distribution, rarely, if ever, appears in the 
skin, connective tissue, or muscles; and carcinoma, which is even less 
exclusive than tubercle in its choice of locality, yet prefers for its pri- 
mary manifestation certain organs, such as the uterus, the mamma, and 
particular regions of the alimentary canal. 

6. The influence of heat and eold, of dryness and, moisture, and of 
atmospheric impurity in predisposing to disease is universally admitted. 
But here, as in some of the cases previously referred to, we are apt to 
confound, and it is difficult to avoid confounding, their indirect effects 
as predisposing agents with their direct effects as exciting causes. And 
further, when we come to test the relative influence of climates and 
of seasons, by the diseases which prevail in them, we find that our 
endeavors to arrive at a just conclusion on the subject are seriously im- 
peded by the coexistence Avith them (but partly no doubt arising out 
of them) of peculiarities of habit and modes of life, by the presence 
of malaria or other special conditions of unhealthiness. Thus, we 
shall all acknowledge the influence of temperature in the production 
on the one hand of bronchitis, pneumonia, and rheumatism, and on the 



26 



THE ETIOLOGY OF DISEASE. 



other hand of sunstroke ; but in these cases no doubt temperature acts 
as the exciting cause. And, again, we shall all be ready to allow that 
remittent fever, hepatitis, and dysentery are characteristic diseases of 
tropical climates; but for the first malaria, not temperature, is wholly 
responsible, and the latter two also are possibly in some cases of malari- 
ous origin. Further, we all know, by personal experience, the ill 
effects of overcrowded close rooms ; and we cannot doubt that deterio- 
ration of health must result from that constant breathing of vitiated 
air to which the children of the urban poor are generally condemned, 
and we shall possibly rightly attribute much of their early sickliness 
and prematurity of death directly or indirectly to this cause. But it 
is certainly difficult accurately to identify either the morbid states which 
it directly produces, or the special predispositions to disease which it 
engenders. 

It is of course beyond dispute that certain diseases prevail exclusively 
or with special severity in certain climates, and that their prevalence 
varies with season, and also with local telluric or hygienic conditions. 
Thus, yellow fever occurs in the West Indies and on the West Coast 
of Africa and some few other localities ; dysentery and hepatic abscess 
are in a peculiar degree diseases of tropical India; Asiatic cholera, 
dengue, plague, all originate, and chiefly or exclusively prevail, in hot 
climates; tubercular phthisis is one of the especial scourges of the 
temperate zone. Again, in our own country at least, thoracic inflam- 
mations are most frequent during the cold seasons of the year, acute 
pneumonia itself being probably most common in the early spring; 
diarrhoeal affections prevail in summer; and many other diseases have 
a tendency, difficult to explain, either to undergo exacerbation or to 
break out, or it may be to subside, at characteristic times ; thus ague 
appears chiefly in spring and autumn, and psoriasis and some other 
forms of skin disease present a somewhat similar tendency. 

It should be added here that the human frame is adapted (fortu- 
nately for us) to live healthily under great varieties of climate, and 
under great extremes of heat and cold; and that probably the effects 
of climate in the production of disease are less due to simple cold or 
heat, dryness or moisture, than to the neglect, on change of climate, to 
adapt our habits of life to the altered circumstances in which we find 
ourselves, and to the effects of sudden and unprepared-for variations 
of temperature. 

7. In close connection with the subject under consideration is that 
of variation in the so-called " epidemic constitution " of successive years, 
and of change in the type of disease. By the term "epidemic constitu- 
tion/' Sydenham, who first employed it, meant a peculiar state of the 
atmosphere, determined by special telluric conditions; to which latter, 
as specific causes, he attributed the development of epidemic diseases, 
such as small-pox, scarlet fever, measles, and plague ; and by variations 
in which he explained the epidemic prevalence of one or other of these 
diseases, and a tendency" (which he believed to exist) for all indifferent 
diseases occurring during such an epidemic to be modified under its 
influence and to assume some of its characteristics. The advance of 
pathological knowledge since his day has proved that most if not all 



EXCITING CAUSES OF DISEASE. 



27 



epidemic disorders spread by contagion, and that there is no atmos- 
pheric or telluric influence to which they are due, nor anything be- 
yond actual contagion which can give, during the presence of Asiatic 
cholera or of small-pox and the like, any of the special attributes of 
these diseases to other prevalent diseases. Nevertheless, it must be 
admitted that there is something remarkable, and indeed something 
inexplicable, in the way in which diseases — not contagious and mias- 
matic only, but simply inflammatory also — become at irregularly re- 
curring intervals prevalent in a high degree over wide areas. In this 
qualified sense the expression, "epidemic constitution," is still not un- 
frequently, and may on the whole be conveniently, employed. 

By the term "change of type in disease," is understood, not the 
transformation of one epidemic disease by gradual steps into another 
disease — a process in which few now believe; but a change in the 
quality of diseases, in virtue of which they present cycles of greater 
and of lesser intensity of attack and of other deviations from the nor- 
mal standard. Such changes are believed to depend, partly on varia- 
tions, referable to the disease itself, partly on "epidemic constitution," 
partly on cyclical changes in the constitution of mankind. There can 
be no doubt that differences of severity and fatality do not unfrequently 
characterize different epidemics of the same disease; and further it is 
beyond dispute that, even during the same epidemic, some persons are 
attacked with much greater or much less severity than others, or have 
the disease in some highly modified form ; and in these senses a varia- 
tion in the type of disease must be fully admitted. There are many, 
however, who still believe that all diseases have undergone a change of 
type during the last fifty years; that they were formerly asthenic, and 
were to be cured by bloodletting, whereas they have now become 
asthenic and demand an exactly opposite line of treatment. It would 
be strange if, while the old descriptions of diseases remain accurately 
applicable (as in fact they do) to those of the present day, and while 
the health of the population has been undergoing gradual improve- 
ment, as it has done (if, at least, we may judge by the diminishing 
death-rates and the improved circumstances of the people), the effects 
of these unchanged diseases on the improved constitutions should be to 
render these latter more helpless during their attacks, and more likely 
to succumb from actual debility. Many will be disposed to admit that 
the change of type has been rather in the medical practitioner than in 
the disease or in the bodily constitution, and that the gradual change 
of treatment has been due, either to the slow advance of knowledge 
with respect to the effects of remedies in disease, or to fashion. 

Exciting Causes of Disease. 

Amongst the predisposing causes of disease which have just been 
passed in review are some which, as was pointed out, act at least as 
efficiently in the direct production of disease. We refer especially to 
those discussed in the paragraphs numbered 4 and 6. It is certain 
that to variations of temperature, combined with changes of hygro- 
metric condition of the atmosphere, a very large proportion of local 



28 



THE ETIOLOGY OF DISEASE. 



inflammations is immediately clue. As undoubted examples may be 
cited common catarrh, bronchitis, pneumonia, pleurisy, nephritis, rheu- 
matism, inflammation of the portio dura causing facial palsy, erysip- 
elas, and various affections of the skin. Again, over-indulgence in 
food, even though the food partaken of be fairly wholesome, causes not 
only sickness and diarrhoea or other forms of gastro-intestinal disturb- 
ance, but leads ultimately to accumulation of fat, plethora, indigestion, 
gout, and various disorders arising out of these. So, on the other hand, 
deficiency of sustenance, or deficiency of essential ingredients of that 
sustenance, induces emaciation, ansemia, debility, degeneration, and 
various special disorders, the direct production of some of which has 
been demonstrated by experiment on the lower animals, and of which 
scurvy affords a notable example. Not far removed from such causes 
as these are the over-exercise or uncler-exercise, or abuse of the system, 
or of component parts of it. We need only refer, in proof of their effi- 
cacy, to the serious consequences which are apt to ensue on sudden and 
very violent muscular efforts, or on long-continued over-exertion of the 
muscular system, to the many injurious effects of sexual excesses, which 
are not entirely due to seminal losses, and to the many nervous disor- 
ders which originate in overwork of the brain, in prolonged wakeful- 
ness, in the unconstrained indulgence of the passions, and the like. 

Without meaning necessarily to exclude the various causes which 
have just been enumerated from classification among them, we may, 
with tolerable accuracy, group the remaining specific causes of disease 
under the heads of mechanical, chemical, and vital; and we may further 
divide them into those which originate within the system on which 
they act (endopathic), and those which attack the system from without 
(exopathic). 

1. Mechanical causes. Exopathic mechanical causes embrace all 
forms of external violence, the results of which fall more particularly 
to the province of the surgeon. Endopathic mechanical causes, on the 
other hand, are of especial importance and interest to the physician. 
They include mechanical obstructions of orifices or tubes, whether these 
obstructions are caused by thickening and contraction of their walls, by 
pressure on them from without, or by impacted concretions. We may 
enumerate as examples stricture, hernia, intussusception, and the lodg- 
ment of gallstones, and all similar obstructions in the ducts of the 
liver and pancreas, in the various urinary passages, in the larynx, 
trachea, and bronchial tubes, at the cardiac orifices, and in bloodves- 
sels. They include also impediments, however originating, to the 
transmission of nerve-currents along the nerves, and moreover dilata- 
tions of arteries and of other tubes and cavities, perforations or rup- 
tures of their parietes, and extravasations or effusions of blood or serum 
and the like. It is obvious, therefore, that agents of this kind are the 
direct causes of a very large proportion of the local diseases to which 
we are liable ; but it is well to observe that they would probably all 
have been considered by the older writers as proximate rather than as 
exciting causes of disease, and that they are in fact in no case the pri- 
mary causes of the morbid processes from which patients suffer. Thus 



EXCITING CAUSES OF DISEASE. 



29 



the patient, who suffers and dies from stricture of the oesophagus or 
bowel, and whose grave symptoms have all been referable to the stric- 
ture, owes his stricture to previous local inflammatory thickening, or 
ulceration, or carcinoma ; and the patient, who dies from the conse- 
quences of mechanical impediment to the passage of blood through the 
mitral orifice, traces the affection of the mitral valve to a long antece- 
dent attack of rheumatic fever. 

2. Chemical causes of disease include all such as are traceable to the 
action of what are generally regarded as poisonous substances, whether 
they be derived from the inorganic or the organic kingdoms, and how- 
ever variously they exert their influence over the system. The great 
majority of these are necessarily exopathic. Some, like the caustic alka- 
lies and mineral acids, destroy the surface to which they are applied ; 
others, like opium, strychnia, aconite, and snake-poisons, undergo ab- 
sorption, and exert their chief influence on particular organs, or on the 
general system. Some, again, being inhaled or swallowed or otherwise 
introduced into the organism, habitually and in minute quantities, pro- 
duce at length specific effects which are held to indicate the existence 
of definite diseases, and are named accordingly. Thus dropped hand 
and colic, or plumbism, are the results of chronic lead-poisoning; mus- 
cular tremors indicate mercurialism, or the ultimate effect of the inha- 
lation of mercurial vapors ; the fumes of phosphorus after a time cause 
necrosis of the jaws ; the habitual use of ergotized cereals for food is 
believed to bring about a peculiar form of gangrene of the lower ex- 
tremities; and not improbably endemic goitre and cretinism are due 
to the constant slow action of some material agent. We must also ob- 
viously include here the poisonous effects which certain articles of food, 
mussels, fungi, sausages, and the like, occasionally induce, and those 
which flow from the habitual use of alcohol, of tobacco, and of opium. 

Endopathic chemical causes are principally such as depend on de- 
fective action of the excretory organs, and the consequent retention in 
the system of effete matters which then act as poisons. The chief 
emunctories for the purification of the blood are the kidneys, liver, 
lungs, and skin. If the kidneys act inefficiently, as they constantly do 
when diseased, urea and other excretory constituents of the urine accu- 
mulate in the blood, and by their presence there at length induce epi- 
leptiform convulsions, dropsy, anaemia, and other symptoms which col- 
lectively indicate the presence of Bright's disease. If the liver fail to 
discharge its normal functions jaundice follows, and with that, and in 
some degree in consequence of it, many other grave symptoms. And 
again, when from mechanical or other impediment to respiration, the 
blood becomes overcharged with carbonic acid, lividity of surface, de- 
lirium, and coma presently supervene. The cutaneous exhalation is 
for the most part merely complementary to that of the lungs and kid- 
neys ; and hence the injurious effects of its arrest are not so obviously 
apparent; at the same time serious consequences are, doubtless, often 
correctly attributed to its suppression. Here we may refer also to the 
ill effects which flow from the accumulation in the blood, of the vari- 
ous ill-defined products of decomposition, which attends the develop- 



30 



THE ETIOLOGY OF DISEASE. 



merit and progress of the specific febrile disorders, and in a greater or 
less degree those of most diseases or pathological processes. 

3. Vital Causes. We now come to speak of that important class of 
causes to which all contagious or infectious diseases owe their origin ; 
causes, which are specific for each specific disease ; which are material ; 
which pass in some way or other from those already affected to those 
who are sound, and implant themselves in their bodies ; which grow 
and multiply therein at their expense, causing characteristic symptoms ; 
which in a greater or less degree are capable of escaping therefrom, and 
of then similarly infecting a second series of healthy persons, and so 
on continually ; and of which none (so far as we certainly know) has 
varied intrinsically in its effects from the earliest record of its operation 
up to the present time, or upon any part of the earth's surface. It is 
at once obvious that these causes are essentially and utterly different 
from those mechanical and chemical causes which have just been dis- 
cussed. It is impossible to conceive the contagiousness of a strictured 
bowel or an apoplectic clot or an attack of jaundice; it is contrary to 
all we know of chemistry that lead or mercury, morphia or the poison 
of the cobra, or a dose of medicine, should multiply within the system. 
But here we have poisons or irritants which do multiply in the system, 
it may be a billion-fold, every unit of whose product is as efficient in 
imparting disease as was the unit from which it sprung. These facts 
seem quite incompatible with any other view of the nature of these 
causes than that they are actual living things. 

That some of them are so is absolutely certain ; we mean parasitic 
animals and vegetables. Of animal parasites, some live and swarm on, 
or in the surface of the body, and readily transfer themselves from one 
body to another, carrying disease with them ; some live in the alimen- 
tary canal, or in the solid organs, and these (though still capable 'of 
communicating the like diseases to other healthy persons) communicate 
them indirectly only, and after having undergone remarkable transfor- 
mations, external to the body of their host, and often in the organism 
of some lower animal. Superficial diseases due to the presence of vege- 
table parasites are also highly contagious. 

With regard to the contagia, properly so called, namely, the infec- 
tious matters to which the several exanthematous and other similarly 
infectious fevers are due, there is far less direct evidence in favor of 
their being living things. Nevertheless some such evidence, to the 
effect that they consist in marvellously minute particles of living 
matter or protoplasm, has been adduced, and will at a subsequent page 
be more fully considered, as also will the question, which need not now 
detain us, as to whether or not they should be regarded as lowly vege- 
table organisms or differentiated particles of the protoplasm of the 
affected body. 

The poison or malaria, on which ague and remittent fever depend, 
has, although it is not communicable from man to man, a certain resem- 
blance to the contagia, both in its mode of infecting the system, and in 
the effects which mark its operation there, and hence is not improbably 
of a like nature with them. 

It seems convenient to advert here to the fact that many inflamma- 



EXCITING CAUSES OF DISEASE. 



31 



tions, originating apparently in indifferent causes, either are inherently 
infectious or acquire under particular circumstances an infective char- 
acter, and that they spread, like the diseases which have just been con- 
sidered, in some cases by direct contact or inoculation, in others, by 
atmospheric carriage. Thus, most practical medical men will readily 
admit the communicability of common catarrh and of tonsillitis, the 
contagiousness under special conditions of even idiopathic erysipelas, 
and the readiness with which catarrhal ophthalmia and impetigo occa- 
sionally spread. Gonorrhoea furnishes a yet more striking example of 
the same fact. These cases are important, because they seem to show 
the possibility of the spontaneous development within the system of 
contagious elements. It is probable that here the contagious property 
resides in the pus or exudation — corpuscles whose development attends 
the inflammatory process. It must be added, however, that a very 
large number of diseases, fundamentally distinct from one another, 
are yet linked together by the common bond of the occurrence in them 
of inflammation as a more or less prominent feature ; that one ten- 
dency of advancing pathological knowledge is to recognize that, in a 
larger and larger number of so-called " inflammations," the inflam- 
mation is not the essential element in the disease, but merely one out 
of a group of several morbid phenomena, all starting from the direct 
influence of some specific cause ; and that hence, perhaps, it may even- 
tually be discovered, that all of these catching inflammations are spe- 
cific diseases dependent on specific causes, in the same sense as is scarlet 
fever or mumps. 

The causes of carcinoma and of other varieties of malignant disease, 
and indeed of proliferating tumors generally, are undoubtedly very 
obscure. It is not difficult to understand that when once a tumor, des- 
tined to be malignant, has made its appearance in any part, the subse- 
quent development of secondary tumors in the neighboring lymphatic 
glands, and in remote organs, may be due to the conveyance thither 
from the primary growth of prolific particles of its specific protoplasm, 
and that hence the diffusion of such tumors throughout the organism 
may, like the diffusion of small-pox throughout a population, be clue 
to a contagium ; but in this case (as probably in certain inflammations), 
to a contagium originating in the living tissues. But this explanation 
throws no light on the primary causation of such growths, and of their 
specific distinctions from one another. They seem frequently, at all 
events, to be induced by the long-continued local operation of non- 
specific causes of irritation, and their specific characters, which are 
perhaps less absolute than they seem to be, may be in some degree 
dependent on the nature of the tissue which becomes irritated into 
overgrowth. 



32 



PHYSIOLOGICAL PROCESSES IN HEALTH. 



GENERAL ACCOUNT OF THE PHYSIOLOGICAL 
PROCESSES IN HEALTH. 

The processes of disease, however widely they may seem to depart 
from those of health, are merely modifications of them, and their types 
mast be sought in the normal physiological processes by which the 
body is developed, grows, maintains itself, and finally dies. It will be 
well, therefore, before considering them in detail, to pass briefly in re- 
view the physiological processes oat of which they arise. 

It is now admitted by physiologists, with almost perfect unanimity, 
that the first origin of every living thing, as well as every living par- 
ticle of the developed organism, consists of a viscid, homogeneous, col- 
orless albuminous substance, known as protoplasm or germinal matter; 
and that this is endowed with remarkable powers, in virtue of which, 
under appropriate conditions of warmth, moisture, and the like, it is 
capable of throwing out processes or otherwise altering its form, and 
thus on the one hand of investing and absorbing solid particles, and, 
on the other hand, of actual locomotion : of growing and maintaining 
itself by imbibing and appropriating the nutritious matters which sur- 
round it, while discharging whatever is superfluous or excrementitious 
or effete : of multiplying by fission or by gemmation : and (in depend- 
ence on its immediate parentage and other conditions) of undergoing 
further development or differentiation, so as to take part in the forma- 
tion of organs, or to become itself an organ performing special func- 
tions. 

Quiescent protoplasm occurs generally in the form of small round 
or oval masses, often presenting an imbedded nucleus, or several such 
bodies, and under many circumstances a thin membranous investment, 
and hence that combination of characters which we recognize in the 
typical nucleated cell. The earliest stages in the development of the 
embryo, and the earliest stages in the development of organs, are char- 
acterized by the abundant formation of cells of this kind (without, 
however, the investing membrane), which are hence termed embryonic 
cells. These bodies therefore stand at the bottom of all growth and 
all development; and it is from their multiplication and from the 
changes which they effect, or which they undergo, that the complex 
organism of the body becomes gradually evolved and finally perfected. 
Thus, in the area germinativa the embryonic cells arrange themselves 
in three layers — an upper or serous, a lower or mucous, and an inter- 
mediate layer; and by a process of development or differentiation, from 
the cells of the upper layer are gradually produced the central nervous 
system and the epidermis wjth its appendages ; from those of the lower 
layer the epithelial lining of the alimentary canal and of the various 
glandular organs which communicate with it; and from those of the 
intermediate layer the vascular system, with the ductless glands, and 
the muscular, connective, and other structures. 

The result of the processes here adverted to is the formation of a 
series of simple tissues, which group themselves here and there into 



PHYSIOLOGICAL PROCESSES IN HEALTH. 



33 



complex specialized masses named organs. These tissues may be ar- 
ranged, according to Virchow, in three categories, the epithelial, the 
connective, and those of a higher grade. 

The tissues belonging to the first category, the epithelial, are evolved 
from the serous and mucous embryonic layers mainly, and comprise 
the epidermis, with the hair and nails, the sebaceous and sudoriparous 
glands; the epithelial lining of the gastro-intestinal mucous membrane, 
with that of the hepatic ducts and other glandular organs connected 
therewith ; the genito-urinary and pulmonary epithelium ; that of the 
serous and synovial cavities of the body ; and the endothelium of the 
bloodvessels and lymphatics. In all these cases, or in nearly all of 
them, the tissue is composed of typical nucleated cells ; that is to say, 
of masses of protoplasm containing a nucleus and invested in a mem- 
branous covering, and so arranged as to be in exact contact with one 
another. Minor differences, differences however of great practical im- 
portance, are observed between the cells of different epithelia; thus 
they vary within wide limits in size and form ; and they vary quite as 
remarkably in the thickness and special characters which their outer 
membrane assumes. In the case of the outer layers of the epidermis 
and in the hairs, the nucleus and protoplasm wholly disappear, and the 
entire cell becomes a mere horny lifeless flake. The functions of epi- 
thelia are very various; some, as those of the skin and of the blood- 
vessels, are merely protective; others, such as that of the surface of 
the mucous membrane of the alimentary canal, absorb ; while others, 
such as belong to the various glandular organs, manufacture and secrete 
products serviceable to the economy, or separate from the blood, and 
excrete matters which are effete or injurious. 

The tissues of the second category, the connective, are developed 
from the intermediate embryonic layer almost exclusively, and pervade 
all parts of the body, with the exception of the epithelia, forming a 
kind of network, in the interstices of which the higher tissues and ele- 
ments of organs are dispersed. They consist of nucleated masses of 
protoplasm, which are often exceedingly minute, and always surrounded 
by a wall of greater or less thickness, sometimes rounded and isolated 
from one another, but in a large number of cases stellate or furnished 
with processes which communicate with those of neighboring cells. 
The essential morphological distinction between epithelium and con- 
nective tissue is, that in the former the cells are in absolute contact, in 
the latter they are always separated from one another by a greater or 
less amount of some intermediate substance — this being either an unor- 
ganized material which has been simply deposited there, or some one 
of the higher living tissues. According to the nature and amount of 
this intermediate substance, or according to peculiarities presented by 
the cells themselves, connective tissues may be divided into certain 
varieties. In ordinary connective tissue, as also in fascia? and tendons, 
the protoplasm is scanty and stellate, and the intervals, which are large, 
are occupied by the ordinary wavy bands of white fibrous tissue and 
a greater or less amount of yellow elastic fibre, both of which are either 
simply secretions from the living protoplasmic masses, or the mere 
mummies of defunct cells. This variety of connective tissue yields 

3 



31 



PHYSIOLOGICAL PROCESSES IN HEALTH. 



gelatine. In cartilage the cells are round or oval, and separated from 
one another by a dense homogeneous elastic substance, which appears 
to be formed by the progressive thickening of the cell- walls and by 
their coalescence, and yields chondrin. In bone, the lacunae and canal- 
iculi mark the position of the cells and their radiating processes, the 
proper constituents of the bone occupying the spaces which these in- 
clude. The central nervous organs and the lymphatic glands are char- 
acterized by a peculiar form of connective tissue, termed retiform, in 
which the essential elements of these organs represent the separating 
material, and in which the proper cellular elements of the connective 
tissue are minute and stellate, and the rays which pass from them are 
very delicate and homogeneous, and inclose exceeding small spaces. 
Mucous connective tissue, which is abundant in the developing foetus, 
is represented at birth by the tissue of the umbilical cord, and through- 
out the remainder of life by that of the vitreous humor of the eye only. 
In this the intermediate substance is fluid, in fact mucus, and contains 
mucin. Lastly, passing by some less important modifications of con- 
nective tissue, it may be pointed out that in the choroid, the spinal pia 
mater, and elsewhere, the proper cells of this tissue contain pigment, 
constituting pigmental tissue, and that in many regions they become 
distended with oil, and then form ordinary fat. 

It is upon the essential elements of the connective tissue, namely, the 
protoplasmic particles, or cells, and the processes springing from them, 
which, with certain modifications of character, are nearly universally 
distributed throughout the organism, that, according to Virchow, the 
action, growth, and maintenance of the organism immediately depend ; 
and just as (to take bone for an illustration) we find certain districts or 
territories (each Haversian system) under the nutritive governance of a 
single bloodvessel, so we find still smaller territories within them (each 
lacunar system) over the welfare of each of which a single cell appears 
to preside. These latter are termed by Virchow " cell-districts." 

The third category of tissues comprises those which are mostly tubu- 
lar, and formed by the juxtaposition and coalescence of cells, or which 
consist of cells, or protoplasm, which have in some other manner un- 
dergone a high degree of specialization. Among these we may name 
nerve-cells and nerves, striped and unstriped muscular fibres, capillary 
vessels, and lymphatics. 

Lastly, complex organs, such as muscles, bones, glands, brain, and 
the like, are formed by the association, in various degrees of com- 
plexity, of several of the above-enumerated tissues. 

Thus the organism may be regarded as consisting of a combination 
of vital and of non-vital elements ; the latter comprising various more 
or less complex chemical compounds which have been prepared and 
deposited through the agency of the living matter, and whose duration 
and subsequent changes are regulated by the action of the living ele- 
ments which are in their immediate vicinity; the vital elements being 
the protoplasmic masses or the nucleated cells, which, thickly dissemi- 
nated, carry on between them all the living functions, and form : 
the universal network of connective-tissue corpuscles : those laminated 
aggregations which constitute the various epithelia and endothelia and 



PHYSIOLOGICAL PROCESSES IN HEALTH. 



35 



the walls of capillary vessels and lymphatics : the massive accumula- 
tions which are observed in the central nervous organs, in the liver, 
lymphatics, and other glands : probably striped muscular fibre, and 
the axis-cylinders and peripheral ends of nerves : and lastly, the living 
corpuscles which are free in the circulating fluids. 

It is important to note here, that the vital properties of protoplasm 

j differ in degree, and in quality, according to its age and the functions 

i to which it has, by process of development, become subservient. Thus 
embryonic protoplasm, and its nearest representatives in the mature 
organism, namely, leucocytes and connective-tissue corpuscles, especially 

j possess the power of multiplication and of differential development; 
whereas muscular fibres and nerve-cells, which stand at the opposite 

1 extremity of the scale, probably never in health undergo proliferation 
or development except in their own special groove. 

The development, growth, and maintenance therefore of the entire 
organism depend essentially on the healthy circumstances, as to nutri- 
tion and the like, of the protoplasmic elements which constitute its 
living parts. All actively living matter is essentially unstable and 
short-lived, and needs for the due performance of its vital acts (which 
are always attended with a certain amount of waste of tissue), suitable 

j food, which it can imbibe and transmute into its own substance, so as 

| at least to supply the place of that which was lost. But it needs also 
the removal of the spent nutritious fluids in which it is bathed, and of 

i those effete and excrementitious matters which it constantly emits. 

For the purpose of providing a constant supply of nutriment, we 
have the blood, impelled by the heart, slowly coursing through the 
capillary bloodvessels, and constantly exuding all save its morphologi- 
cal elements through their delicate parietes into the extravascular tis- 
sues around, and occasionally perhaps exuding those morphological 
elements themselves ; and for the purpose of maintaining a constant 
removal of the spent pabulum, and of effete matters, we have the fluids, 
which have been thus exuded, as constantly removed, partly by the 
agency of the venous radicles, but mainly by the lymphatic vessels, 
which have their origin in the meshes of the capillary network, and in 
the very spaces in which the protoplasmic elements themselves are 
situated. 

The nutritious matters of the blood are supplied to it primarily from 
I the alimentary canal. Food, after having been triturated and swal- 
lowed and acted on by the secretions of the various glandular organs 
which discharge their contents into the stomach and bowels, becomes 
I absorbed at the surface of the mucous membrane, the fluid and more 
| readily diffusible parts by the capillary bloodvessels, the fatty and albu- 
minous matters by the lymphatics. Those substances which enter by 
: the former route, after passing through the liver and perhaps under- 
j going some change there, mingle with the general mass of the blood ; 
I those which enter by the lymphatics first traverse the lymphatic glands, 
carrying with them thence the white corpuscles which these glands 
! manufacture, and then like the former blend with the circulating fluid. 
| But the surplus nutriment which escapes from the capillary vessels into 
, the tissues external to them is also taken up mainly by lymphatic ves- 



36 



PHYSIOLOGICAL PROCESSES IN HEALTH. 



sels, and this again, after passing through lymphatic glands, and de- 
riving thence morphological elements, mingles, like that derived from 
the alimentary canal, with the blood-stream. Lastly the important 
secretions furnished by the mucous membrane of the alimentary canal, 
and by the viscera which discharge into it, are reabsorbed in large 
proportion with the food, and thus re-enter the circulation. 

Effete matters derived from the waste of the organism are dissolved 
in the. fluids that are also the carriers of nutritious matter ; and are 
removed from the parts in which they are produced by the same chan- 
nels, namely, the veins and the lymphatics ; and mingling with the 
blood are there further reduced by the reducing agency of the oxygen, 
which it is the function of the lungs to furnish to the blood. Thus 
they become converted into diffusible compounds of comparatively 
simple constitution, which are then separated from the blood by appro- 
priate emunctories, carbonic acid by the lungs, nitrogenous compounds 
and salts by the urine and by the skin, and the coloring matter of the 
blood by the kidneys and the liver. 

Presiding over the processes of nutrition, and to a great extent regu- 
lating them, yet itself entirely dependent upon them for the means of 
its material and functional activity, is the nervous system, comprising 
the central organs, the nerves, and the end organs of the nerves. By 
means of the nerves every part of the organism, almost every proto- 
plasmic mass probably, is brought directly or indirectly, through the 
intervention of ganglia or of the central organs, into relation with the 
other elementary parts of the organism. Sensations or impressions 
received by the peripheral terminations of afferent nerves are conveyed 
instantaneously either to some nerve-ganglion, or to the spinal cord, or 
to the brain, or to all of them, and reflected thence along the efferent 
nerves, certain responsive influences are transmitted, which, according 
to their destinations, result in muscular movement or in glandular ac- 
tion. Thus the central organs are kept informed of what is going on 
throughout the organism ; and thus (to omit all reference to their influ- 
ence over the voluntary muscles) by acting on the walls of the heart 
and on those of the bloodvessels, they regulate the supply of blood to 
parts, and so influence their nutrition and the activity of their special 
functions : by acting on the walls of gland-ducts they modify the rate 
of escape of the products of the glands : and by the direct agency of 
the trophic nerves (which many physiologists now believe to exist), 
they probably exert a direct influence over the action of the essential 
elements of secreting glands. 

Ere we bring these preliminary physiological remarks to a conclu- 
sion, a more direct reference must be made than has hitherto been 
made to the fact that decay and death seem to be essential elements in 
the normal processes of life. It has already been pointed out that 
every act of life is attended with some waste of tissue, and it has been 
incidentally remarked that livipg protoplasm is essentially unstable 
and short-lived. It must be added that every part of the organism 
has a limited duration, which is far shorter than that of the normal 
duration of the body which it contributes to form, and that such parts 
are removed either by slow disintegration and degeneration or are cast 



PHYSIOLOGICAL PROCESSES IN DISEASE. 



37 



off in mass. We need only here advert, in exemplification, to the shed- 
ding of the epidermis, and of the elements of excretory glands, to the 
constant removal and re-formation of bone-tissue, to the generation and 
destruction of blood-corpuscles, to the atrophy of the uterus after par- 
turition attended with fatty degeneration of its muscular elements, and 
to the even more complete destruction by similar processes of the 
Wolffian bodies during foetal life, and of the thymus gland during the 
first few years of extrauterine existence. It must never be forgotten 
that atrophy and degeneration of organs and tissues are normal physio- 
logical processes of old age, and that somatic death, in which they 
culminate, is their normal termination. 



PHYSIOLOGICAL PROCESSES IN DISEASE. 

If we consider carefully the intimate processes of disease, we shall 
easily recognize the fact that they consist essentially in nutritive modi- 
fications of the protoplasmic or vital elements of the tissues ; that under 
the influence of abnormal or unwonted stimuli (including the stimulus 
of excessive nourishment), these enlarge, or multiply, or differentiate; 
that when insufficiently stimulated or fed, they undergo atrophy or 
degeneration, or perish ; and that, as a necessary consequence of such 
changes, their functional attributes become heightened or impaired, or 
more or less profoundly modified. Thus, on the one hand, we get 
simple hypertrophy, or inflammation, or heterologous growth, and, on 
the other hand, fatty, calcareous, and other forms of degeneration ; and 
thus again we get functional derangements too numerous to mention, 
which constitute so large a proportion of the symptoms of disease. But 
when we look to the marvellous complexity of the organism, to the 
intimate anatomical relations which subsist between the vascular and 
the nervous and other subordinate systems and organs, and to the cor- 
relation and mutual dependence of the various functions which all these 
different component parts of the organism are called upon to perform, 
and consider that the healthy structure and function of each is involved 
in a greater or less degree in the similar integrity of every other ; we 
must at once admit (what the slightest practical experience will con- 
firm), that we cannot limit our view of morbid processes to these in- 
timate changes alone, but must embrace within it those modifications, 
or so-called " diseases," of particular organs to which such changes give 
rise, as well as those further nutritive and functional disturbances 
which, in a variety of ways (mechanical, chemical, and other), " dis- 
ease" of important organs necessarily evokes in the living particles 
elsewhere throughout the system. We proceed to discuss at length the 
several matters here adverted to. 



38 



MORBID GROWTH. 



(1.) MORBID GROWTH. 

General Observations. 

Growth and Development of Cells. — Whenever the protoplasmic par- 
ticles or cell-elements of a part are stimulated to unwonted growth, 
they first, if stellate or fusiform or caudate, retract their processes, tend 
to assume a more uniformly rounded shape, increase in bulk, and be- 
come somewhat turbid, or minutely and indistinctly granular; and 
then, by internal gemmation or fission, each cell gives origin to two 
or more smaller cells, which in their turn repeat more or less accu- 
rately the same processes of growth and proliferation. The results 
of such stimulation, so far as regards the cells themselves, are that 
sometimes the newly-generated cells acquire in all respects the same 
characters as had formerly belonged to their immediate ancestors, that 
sometimes they retain permanently the immature or embryonic condi- 
tion which represents the early or indifferent stage of nearly all cell- 
growth, and that sometimes again they undergo development into cel- 
lular bodies which differ materially in size, form, and attributes from 
those which gave them origin. Simple hypertrophy or hyperplasia 
furnishes an example of the first of these alternatives, inflammatory 
cell-production of the second, and heterologous tumors of the last. 

Conditions associated with Overgrowth. — But where there is exagger- 
ation of cell-growth, there necessarily is also at least proportionate 
exaggeration of the various conditions which are subsidiary to such 
growth, namely, exaggerated afflux of blood, exaggerated accumula- 
tion of nutrient fluid, exaggerated molecular destruction, and exagger- 
ated efflux of superabundant and effete materials. Increased afflux of 
blood is determined mainly by reflex dilatation of the arteries, capil- 
laries, and veins, which minister to the needs of the affected part, and 
in a subordinate degree by increased force and frequency of the heart's 
contractions, and produces one form of what is known as " congestion." 
Increased accumulation of nutrieut fluid in the extravascular tissues is 
due to the preternaturally abundant escape of it from the dilated capil- 
laries, an escape in some degree doubtless dependent on the vital influ- 
ence exerted by the protoplasm of the capillary walls, and by the 
overgrowing protoplasm external to them. The tissues become conse- 
quently swollen, soft and juicy, and in a greater or less degree " drop- 
sical." All vital activity, whether this manifests itself by material 
changes or by functional excitement, is attended with molecular disin- 
tegration, which has some exact quantitative relation with it ; and 
hence increased vehemence of growth and of reproduction is neces- 
sarily accompanied with a proportionately increased production of 
effete and excrementitious matters. But, in addition, undue rapidity 
of cell-growth and development always involves a corresponding ten- 
dency to fall into premature decay and dissolution ; and hence arise 
fatty and other forms of degeneration, the products of which accumu- 
late, and mingle with those of molecular disintegration, so that the 
fluids of the affected region tend to become surcharged with innutri- 



LOCAL SPREAD. 



39 



tious, waste, and often noxious materials. The increased absorption 
which takes place at the part is dependent probably, in some measure, 
on the more active passage of fluid by endosmosis through the walls of 
the venous radicles, but is certainly due mainly to the more direct 
action of the lymphatic vessels. Indeed it is almost impossible to 
suppose that those slightly diffusible substances, albumen and fibrin- 
ogen, should, in the face of the opposing pressure from within the 
bloodvessels, be capable of re-entering them, or that solid particles, 
whether indifferent or specialized, should be removable by any other 
route than that furnished by the open mouths of the lymphatics. 
That these are the main agents however in the removal of probably 
everything save a variable proportion of water and of dissolved salts, 
is shown by the tendency which, when largely overworked, they and 
the glands in their course have to become enlarged and presently 
inflamed, or involved in the identical processes going on at the seat of 
absorption. 

Migration of Leucocytes. — One of the most interesting phenomena, 
connected with this subject of local proliferation, is the fact, stated 
manj years ago by Dr. Addison, and since then clearly established by 
the experiments of Cohnheim and the later observations of many other 
physiologists, namely, that in artificially produced irritation or inflam- 
mation of the tissues of the frog, after retardation of the current of 
blood in the vessels of the part has taken place, the white corpuscles 
begin gradually to penetrate the vascular walls, and presently pass 
completely through into the tissues external to them. It has been fur- 
ther shown that these emigrant corpuscles take an active personal part 
in the proliferation which ensues; that is to say, that they then, as well 
as the proper protoplasmic masses of the part, give origin by gemma- 
tion or fission to new generations of cells. How far this process con- 
tributes to inflammatory proliferation in warm-blooded animals, or may 
be regarded as an essential element in the development of non-inflam- 
matory growths, is at present in great measure a matter of inference. 
Still there are many good grounds for regarding it as an important 
item in all cases of abnormal cell-proliferation. And it is far from 
unlikely that it may be equally importantly concerned in the normal 
processes of growth and development. 

Tendency of Morbid Growth to spread Locally. — Morbid cell-devel- 
opment, occurring primarily at any one spot, has generally a tendency 
to spread in the neighborhood of that spot, and not unfrequently a 
tendency also to repeat itself elsewhere in the organism. Sometimes, 
indeed, many such foci of proliferation arise simultaneously. The 
direction of the local spread of overgrowth is in most cases largely 
determined by the structure and connections of the tissue or organ in 
which it has originated. Thus growths beginning in the cutis or in the 
mucous membrane are most apt to limit their extension to these mem- 
branes ; and the same rule applies to the kidney, ovary, and other 
organs. Nevertheless, in many cases the morbid process tends gradu- 
ally to involve all adjoining structures. This local spread is sometimes 
effected by the progressive involvement of the healthy tissues imme- 
diately adjoining the focus of disease ; and very often partly by this 



40 



MORBID GROWTH. 



process, but partly also by the appearance of new foci of disease in the 
vicinity of the primary focus, and by their gradual coalescence with it 
and with one another. It is certain too that this local extension is 
sometimes determined by the lines of capillary lymphatics and blood- 
vessels. 

Tendency of Morbid Growth to become Generalized. — The tendency 
to the simultaneous or consecutive occurrence of the same kind of mor- 
bid proliferation in different, and even remote, parts of the organism 
is traceable to a variety of causes, presents obvious and characteristic 
differences, and has therefore a widely different significance indifferent 
cases. The matter is one which deserves, and indeed demands, con- 
sideration, and we proceed therefore to discuss it in some detail. A 
person, in apparently the best of health, finds that he has a fibrous or 
a fatty tumor in the subcutaneous connective tissue, or an osseous or 
cartilaginous tumor growing from the shaft of some bone; and in a 
short time probably it is ascertained that many other tumors, identical 
in character with the one first detected, are making their appearance in 
the connective tissue or the bones (as the case may be) of different parts 
of the body. Now it is indubitable that we have here a curious ten- 
dency in certain tissues of the body to undergo special morbid changes. 
To what is this tendency due? The first-formed tumor may have been 
distinctly traceable to some local injury. Has the growth which re- 
sulted from that injury so infected the system as to have led to the 
multiple development of similar growths throughout the same tissue 
as that which was primarily involved ? Or have all the tumors (in- 
cluding the first) resulted from the operation of some independent mor- 
bid irritant or poison which has been generally diffused throughout 
the system ? Or is there some inherent weakness or vice in the particu- 
lar tissue, which has become affected, which renders it liable to take on 
specific morbid proliferation under the influence of mechanical violence 
or any other indifferent cause? In the particular examples which have 
been adduced (and many similar ones might be added), the last of the 
three suggested explanations will doubtless be regarded generally as 
the only tenable one, and probably it is the correct one. At all events, 
we have no grounds for assuming, from the presence of cachexia, or of 
other associated abnormal conditions, that any poisonous matter either 
is or has been present in the system, or from the presence of lymphatic 
implication that the primary seat of disease has been the source of 
infection. 

The case, however, is not quite so simple as it appears at first sight, 
nor is its explanation quite so obvious. The skin, like the bones or the 
connective tissue, constitutes a special constituent of the organism, and 
like them (though in a still higher degree) is liable to many morbid 
conditions which are peculiar to itself, and which may be distributed at 
intervals over its surface. Now a patient may have psoriasis, beginning 
perhaps in a patch on each elbow or on each knee, and diffusing itself 
in spots over the greater part of the body. His father may have suf- 
fered from the same disease, and his brothers and sisters may also be 
subject to it. The case is one of hereditary predisposition. Now, no 
one probably here would dream of suggesting that the spread of the 



GENERALIZATION. 



41 



disease was due to the infecting influence of the patches which first ap- 
peared on the knees or elbows; and certainly no direct evidence could 
be adduced in favor of its dependence on any morbid irritant carried 
by the blood. The case indeed would doubtless be regarded as equiv- 
alent, in point of origin, to that of multiple fibrous tumors or exostoses. 
But another patient also has psoriasis, differing a little in details of 
distribution and color, but (unless we go into the previous history and 
subsequent progress of the case) in no other respect probably from that 
observed in the former patient; and further, at the time of observation 
he may appear to be in every other sense perfectly healthy, and to have 
no indication whatever of constitutional disturbance. He had a chancre, 
'however, some time previously, and his skin disease is due to the 
syphilitic poison then received into his system. Or, to take another 
example, an apparently healthy person becomes liable, without obvious 
cause, to urticaria, and suffers from it off and on for years, perhaps the 
remainder of his life. It is little, if at all, influenced by diet or habits, 
and altogether uncontrollable by medical treatment, and moreover may 
be readily induced by a pinch or scratch. There seems to be no reason to 
regard this, any more than psoriasis, as the result of a specific irritant 
working from within. But another person takes a meal of mussels, 
and presently, together with more or less violent constitutional dis- 
turbance, presents an abundant urticarial eruption. Now here the 
relation between cause and effect is as obvious as in the case of syphilitic 
psoriasis. We have thus clear evidence that both psoriasis and urti- 
caria are producible by the local operation of special poisons which 
have been introduced from without, and have infected the system, and 
that the former may be produced without any necessary contempora- 
neous manifestation of other symptoms of disease. But do not these 
facts throw a little doubt on the non-specific origin of so-called " idio- 
pathic" psoriasis and urticaria, and hence also on the assumed non- 
specific cause of fibroma, exostosis, and the like ? 

Nevertheless, while it is certain that many specific affections of spe- 
cific tissues are certainly traceable to the influence of specific irritants, 
it seems not improbable that other such affections are simply due to 
the influence of indifferent causes acting on parts which have become 
specially apt to take on such morbid action. At the same time it must 
be admitted that the absence of collateral evidence of the presence of 
systemic poisoning by no means proves the absence of such poisoning ; 
and further that the apparent commencement of the above or any like 
lesions from an injury in no degree renders it certain that that injury 
was its essential cause. 

The difficulties which have just been briefly considered are equally 
apparent in the case of carcinoma and other infecting tumors. These, 
like exostoses and fibromata, become multiplied throughout the organism, 
and like them repeat in each newly-formed growth the characteristics 
of the growths which were first developed. But they differ essentially 
from them in being heterologous in structure from the tissues wherein 
they first make their appearance, and in the fact that they are not, or 
at all events are not so obviously, limited in their further distribution 
to one special form of tissue. They differ from them also in the fact 



42 



MORBID GROWTH. 



that, however we may explain their first appearance, the first-formed 
mass inoculates the system with the disease, as truly as the subcutane- 
ous insertion of the variolous contagium inoculates a person with small- 
pox, and exactly in the same way as a chancre infects its subject with 
syphilis. Thus if a carcinomatous tumor makes its appearance in the 
testicle, the patient for the time seems, and probably is, free from dis- 
ease elsewhere; but presently other organs become affected with the 
same disease, and in a certain sequence. First we find the lymphatic 
glands, into which the testicular lymphatics run, involved; these are 
the lumbar glands; and next, after a further interval, the disease 
appears simultaneously in many tissues and organs. If a patient has 
carcinoma of the glans penis, the next manifestation of the disease occurs" 
exactly where the effects of syphilis first reveal themselves subsequently 
to the appearance of a chancre of the same part, namely, in the in- 
guinal glands. And in this case again at a later period the disease be- 
comes generalized. The same rule applies equally to cancer of the 
breast, of the uterus, of the pylorus, and indeed to any primary cancer 
no matter where it arises. First the lymphatic glands in the neighbor- 
hood, and especially those which lie in the direct route between the 
tumor and the thoracic duct, become the seat of carcinomatous disease, 
and then later on patches of carcinoma reveal themselves in many 
organs. It must be added also that in diseases of this kind every 
secondary tumor is equally infective with that which was first devel- 
oped; and that consequently, just as the primary tumor causes disease 
in the lymphatic glands related by position to its seat, so each secondary 
tumor tends sooner or later to infect the lymphatic glands which are 
in immediate connection with them. 

Tendency of certain Morbid Growths to limit their Distribution to cer- 
tain Tissues or Organs. — But although carcinomatous tumors, and such 
other growths as are related to them by their mode of dissemination from 
a primary focus of disease, undoubtedly tend when they become gene- 
ralized to involve a much wider range of tissues and organs than do 
fatty tumors, exostoses, and the like, it is certain nevertheless that they 
have preferences, and that these preferences are in some degree charac- 
teristic for each species of tumor, or, in other words, that they have 
elective affinities; and further that, as Yirchow distinctly points out, 
the parts in which such affections usually originate are especially the 
parts which their secondary manifestations seem to avoid; and con- 
versely. Thus tubercle and carcinoma, although severally disposed to 
attack secondarily a large number of organs, and many of them in 
common, present obvious peculiarities of distribution ; for while both 
of them are specially apt to attack the lungs and brain and serous 
membranes, carcinoma is yet more disposed to attack the liver, which 
tubercle generally avoids, and tubercle has a special affinity for the 
mucous membrane of the bowels and for the spleen, in both of which 
situations secondary cancer is certainly rare. And thus again, while 
primary carcinoma is common in the breast, the womb, and the alimen- 
tary canal, those parts rarely become involved when carcinoma origi- 
nates in some other part of the system. The cause of the apparent 
capriciousness of distribution of secondary growths is very obscure. It 



DYSCR ASIA. 



43 



1 is easy of course to understand why the lungs, which form a kind of 
| filter to the universal blood, should be especially liable to them, and 
| why the organs which receive a specially copious supply of blood or 
j have such arrangements of vessels as retard or lengthen its passage 
! through them (the liver and the kidneys, for example) should be 
affected more frequently than others. But neither such conditions, nor 
j others connected with the relative functional activity of organs, although 
I doubtless influential, are sufficient alone to explain the phenomenon. 
It has recently been ascertained that lymphatic tissue is very abun- 
dantly distributed throughout the organism; and there is some reason 
to believe, that the generalization of both tubercle and lymphosar- 
coma is connected with this fact; and that it depends either on some 
special proclivity to morbid processes which this tissue acquires under 
certain constitutional conditions, or else on the circumstance that the 
lymphatic tissue is the appropriate soil for the germination of the seeds 
of lymphosarcoma and of tubercle. The latter is probably the correct 
explanation ; and probably, indeed, apparent capriciousness is, in all 
other cases also, mainly dependent on the special suitability of different 
tissues and organs for the reception and growth of different specific mor- 
bid elements — an explanation which is in entire accordance with all 
that we know of the behavior of the morbid poisons or contagia of the 
exanthemata, and of that of animal and vegetable parasites, and, it may 
be added, of the behavior of other organic and inorganic substances 
admitted into the organism. 

Connection of Dyscrasia loitli the Origin of Morbid Growths. — Nothing 
which has yet been said relates in any degree to the question of the 
primary origin of infecting growths ; it has simply been shown that 
when once developed they become the sources of specific infection to 
their unfortunate possessors. This primary origin is referred by many 
persons to a dyscrasia or morbid condition of system, itself supposed to 
be produced by the presence of some morbid matter or influence within 
the blood ; and indeed Mr. Simon, who formerly adopted that view, 
regarded a carcinomatous tumor as a newly-developed organ, whose 
express purpose was to effect the separation of that morbid poison from 
the organism. There are several considerations which lend counte- 
nance to this view. Thus, when a person exposed to atmospheric 
changes contracts pneumonia or any other variety of internal inflam- 
mation, an interval occurs between the exposure and the commencement 
of the inflammation, during which some abnormal condition of the sys- 
tem, a dyscrasia, is present. So again the incubative stage of small-pox 
or measles is a period of specific dyscrasia. And further, as regards tuber- 
culosis at all events, we know that it is apt to come on in individuals 
who have fallen into general ill-health. But, on the other hand, these 
examples are none of them strictly analogous to that of carcinoma ; and 
one indeed (that of the exanthem) fairly considered tells the opposite 
way ; for its incubative period corresponds, not to a supposed incubative 
stage of carcinoma, but to the period which elapses between the first 
appearance of a tumor and its generalization. Besides, in the great 
majority of cases in which we have the opportunity of observing the 
. first manifestations of carcinoma, these are certainly not preceded by 



44 



MORBID GROWTH. 



any evidence of ill-health, and moreover no such evidence becomes 
apparent until the patient is obviously beginning to suffer, directly or 
indirectly, from the effects of his disease. 

The existence then of initial carcinomatous and other such specific 
dyscrasiae may fairly be denied; at all events, the only proof of their 
existence is the appearance of those very lesions which we attribute to 
their influence. And hence the only sense, in which such a dyscrasia 
can be conceded, is the sense in which we should admit a preliminary 
dyscrasia as the source of enchondromata, exostoses, fibrous tumors, 
leprous patches, and the like — a dyscrasia, that is to say, which is of 
limited distribution, and consists simply in a tendency (congenital or 
acquired) in certain parts of the body to undergo a special kind of pro- 
liferation under the operation of various forms of irritation. It need 
not of course be denied here, any more than in the case of non-infective 
growths, that such a tendency may exist simultaneously in various parts 
of the body ; and that hence, although it is certainly not the rule, there 
may be a concurrent primary outbreak of infective growths in two or 
more localities. 

Secondary Dyscrasia. — But although a state of cachexia, or a dys- 
crasia, is not an essential antecedent of primary infective growths, there 
is no doubt that a condition of cachexia speedily follows upon their 
appearance. The fact has already been adverted to that, from any 
focus of morbid proliferation, there is an abnormally large reflux of 
nutrient fluid into the general circulation, partly by the veins directly, 
but chiefly by the lymphatics, and that this nutrient excess is largely 
charged with effete and other morbid products, generated in the diseased 
area. These products comprise : the ordinary waste-materials, carbonic 
acid, urea, and the like: materials which are traceable to the special 
chemical constituents of the part involved, earthy matter if it be bone, 
phosphates if it be brain: and probably also fibrin or fibrin-produc- 
ing substance, which, as Virchow suggests, is manufactured at the seat 
of disease, and by its removal thence by the lymphatics overcharges the 
blood and gives it its inflammatory character. But in addition, spe- 
cific affections yield specific elements, which also traverse the lym- 
phatics, and presently mingle with the blood. What these are is not 
accurately known; but probably (judging from the analogies afforded 
by the infectious fevers) they are living protoplasmic particles evolved 
by the primary growing mass, which become arrested in the lymphatic 
glands and then infect them, either by growing parasitically among 
their elements, or by imparting (sperm-like) to these latter specific 
properties; and which presently are shed thence, in new generations, 
through the thoracic duct into the blood-stream to sow themselves in 
distant organs. Now in all these processes, it is obvious that we have 
ample sources of deterioration of the general health, and of functional 
disturbance of various parts of the organism — in other words, of a 
secondary dyscrasia. But it is obvious, also, that the degree and char- 
acter of the dyscrasia will vary according to the peculiarities of the 
morbid process to which it is due, and especially that that accompany- 
ing the development of infective growths will be attended with specific 
characteristics. Further, more or less in most cases, but in the last 



MALIGNANCY AND INNOCENCY. 



45 



more particularly, dyscrasia will probably be largely increased by the 
constant drain of nutriment which the growth and ulceration of tumors 
necessarily involve, and by the obstacles which, by pressure or other- 
wise, these so often interpose to the due performance of important or 
necessary functions. 

When secondary dyscrasise are present we often find that some 
mechanical injury, or the result of some such injury, appears to attract, 
as it were, specific morbid processes. When, for example, a patient is 
suffering from constitutional syphilis, a local outbreak is often thus 
determined. It is probable that this phenomenon is due to the fact 
that parts, in which certain non-specific morbid processes are in prog- 
ress, furnish a specially suitable soil for the growth and development 
of the specific elements of disease, which happen at that time to be 
circulating in the blood. The interesting experiments of Chauveau 
seem strongly to confirm this view. He found that, on injecting putrid 
fluids containing bacteria into the blood of healthy animals, no special 
consequences beyond constitutional disturbance necessarily followed ; 
but that if, after injecting them, the operation of twisting, and thus 
strangulating, one testicle was performed (an operation common in 
France and leading to the gradual wasting of the organ) violent inflam- 
mation with sloughing, attributable probably to an abundant devel- 
opment of bacteria, took place in the injured part, the opposite healthy 
testicle remaining all the time altogether unaffected. 

Meaning of Terms Malignant and Innocent. — It may be well here 
briefly to explain the meaning which attaches to the terms " Inno- 
cent" and "Malignant," as applied to morbid growths. Malignant 
is almost synonymous with infecting, but not quite; for a chancre and 
an inoculated variolous pustule are both infecting growths, yet not 
malignant. The word therefore implies something more than is pre- 
sented by either of these affections. It implies in fact, additionally, 
that the morbid process going on in any one locality has a tendency to 
invade all the tissues which are about it, and has further no tendency 
whatever to become cured, or even to remain quiescent. A malignant 
tumor may be defined therefore as one which tends to involve all sur- 
rounding structures, to disseminate itself through the agency of the 
lymphatics and veins, and has no tendency to spontaneous cure. The 
term " innocent" is mostly understood to signify simply that a tumor 
is non-infective. Malignant tumors often present other characters 
which, though not necessarily associated with malignancy, are yet 
highly suggestive ; these are, tendency to recur after removal, abundant 
and rapid cell-growth, softness and juiciness of tissue (the juice being 
milky), great vascularity, and marked differences of texture as com- 
pared with that of the parts in which they originate. 

A very characteristic feature of most morbid proliferations of tissue, 
whether they be malignant or innocent, is their quasi-parasitic nature, 
their tendency to grow, and to maintain themselves, independently of 
the general health of the body in which they are developed, and from 
which they derive their sustenance. Thus, a large abscess, so far from 
becoming starved by the gradual emaciation of the body in which it is 
present, will often go on increasing even more rapidly as the body 



46 



HYPERTROPHY. 



dwindles away. And so also, enchondromatous, fatty and carcinoma- 
tous tumors, and tubercle, show no signs of impaired vigor of growth, 
while the patient is progressively wasting under their influence. Over- 
nutrition and under-nutrition of the body of their host are alike with- 
out obvious influence over their progress. 

Hypertrophy. 

The term hypertrophy is commonly used loosely of all organs or 
tissues which, from no matter what cause, have undergone abnormal 
increase of bulk. Thus a liver enlarged by fatty deposit or lardaceous 
infiltration is often said to be hypertrophied, as also is an ordinary 
swelled testicle, or a lymphatic gland, affected with tubercle or car- 
cinoma. But in such cases as these the enlargement is due essentially 
to the deposit of some extraneous matter, or to the development of some 
inflammatory or other morbid growth ; and the normal structure of the 
organ, so far from being increased in quantity or size, has probably 
undergone a greater or less degree of atrophy or degeneration. 

True hypertrophy of an organ consists, either in an enlargement of 
its essential elements, or in an increase in their number. By Virchow 
the latter variety of overgrowth has been distinguished as hyperplasia. 
The former process is exemplified by the enormous enlargement of the 
unstriped muscular fibres of the womb which takes place during the 
progress of pregnancy ; the latter by the overgrowth of bone, which is 
effected simply by the multiplication of its elementary parts. It is 
very difficult, however, in many cases to determine positively by which 
of these two processes an overgrown organ has become enlarged ; and 
doubtless they frequently co-operate. 

Of all morbid processes, simple hypertrophy is that which approaches 
probably nearest to the processes of health ; indeed it is mostly due to 
the operation of the very causes which produce normal increase of bulk, 
and is in a very large number of cases, for a time at least, protective 
or otherwise beneficial. Hence, it is difficult to draw the line between 
that normal growth of the heart, which comes with advancing years 
and activity of body, and that excess of enlargement, which sustained 
and over-violent exertion brings about, and which presently reacts in- 
juriously. Again, how much more speedily would obstructive disease 
at the cardiac orifices prove fatal, if hypertrophy of the heart's walls 
did not naturally follow upon their efforts to overcome that obstruction. 
Similar morbid hypertrophies of the muscular parietes of hollow viscera 
are alw T ays apt to arise under circumstances which compel them to long- 
continued unwonted action. We may refer to the hypertrophy of the 
stomach which occurs when the pylorus is diseased, to that of the in- 
testine in cases of intestinal obstruction, and to that of the bladder or 
of the ureter, or of the ducts of various glands when mechanical im- 
pediments which prevent the escape of their contents are present. Such 
consecutive, and often beneficial, hypertrophies are not confined to 
muscular organs, but may occur in glands, in bones, and elsewhere; 
in the kidney, for example, when, in consequence of the destruction of 
one, its fellow attains unwonted dimensions, or when both undergo 



INFLAMMATION. 47 

enlargement under the influence of diabetes ; in the bones, as we see 
when a protective buttress is formed in the concavity of a curved 
rickety tibia. 

Not all forms of hypertrophy, however, are the consequence of the 
attempts of organs to adapt themselves to conditions of increased work. 
Hypertrophies which are essentially abnormal, and have no beneficial 
tendency whatever, arise in some cases from the direct influence of the 
nervous system ; in others (and these are the most frequent), from the 
stimulus of excessive supply of nourishment. Amongst the former 
may be included the hypertrophy of the heart, which long-continued 
nervous palpitation induces, and that form of goitre which occurs in 
"Graves's" disease: amongst the latter, that general enlargement of 
the lower extremity (in which the bones become longer and thicker 
than those of its fellow, and the other structures of the limb propor- 
tionately increased), which we meet with in cases where, owing to 
obstruction and dilatation of its lymphatics, the whole member be- 
comes succulent with nutritious fluid. A particular form of hyper- 
trophy of the tongue in children, and the overgrowth of the skin and 
subcutaneous connective-tissue in elephantiasis, are also largely due to 
this last condition. 

Inflammation. 

The collective morbid phenomena which are included under this 
term occur as an essential, or an accessory, part of the great majority 
of diseases. They represent the reaction of the system, or of parts of 
it, against the injurious effects of irritants w 7 hich are morbid either 
from their amount or from their quality, the efforts by which nature 
endeavors to destroy, or to counteract, or to throw out what is noxious, 
and those by which she strives to repair what has been injured, and to 
restore what has been destroyed. It need scarcely be added that in- 
flammation often goes far beyond, or falls far short of its aim, and often 
acts as it were capriciously and blindly. 

The classical local signs of inflammation are redness, sivetting, heat, 
and pain. These are no doubt all present in the majority of cases ; the 
redness being due to accumulation of blood in the dilated bloodves- 
sels ; the swelling, partly to this dilatation, partly to simple effusion, 
partly to growth of tissue ; the heat in some degree to the increased 
afflux of blood, in some degree to the rapid disintegration that is in 
progress ; and the pain to pressure on the sensory nerves, or to their 
implication in the morbid processes. But neither redness, swelling, 
heat nor pain, is absolutely essential to inflammation; they are simply 
to be regarded as common results or accompaniments of that process. 

Inflammation consists primarily and essentially in an unnatural irri- 
tability, and a tendency to undue proliferation, of the protoplasmic 
elements of a part; these giving rise, not as in simple hyperplasia to a 
mere increase in the number of the normal elements, but to cells which 
tend to resemble leucocytes, or embryonic cells, and which never go 
beyond the formation of simple granulation tissue or some variety or 
modification of the various forms of connective tissue. The connec- 



48 



INFLAMMATION. 



tive-tissue corpuscles are those in which inflammatory proliferation 
chiefly takes place; but all protoplasmic masses, including those of the 
epithelia, those connected with the nerves and striped muscles, and 
those also which, by their coalescence form the walls of capillary vessels, 
may participate in the process. As doubtful exceptions may be named 
the cells of the central nervous organs, the proper liver-cells, and other 
cells which have attained a high place of development. 1 But in con- 
nection with these extravascular changes, vascular phenomena speedily 
ensue, and at once take an active share in the processes which are going 
on. Among the phenomena which occur in the course of inflamma- i 
tion or follow upon it are, exudation, suppuration, ulceration, gangrene, 
and granulation or repair. 

Extravascular Processes. — The extravascular processes of inflam- 
mation may be best observed, observed freest from complication, in 
parts which are devoid of vessels, such as the cornea, cartilage, and 
portions of the mesentery. If a costal or articular cartilage be ex- 
cited to inflammation by the mechanical removal of a portion of its 
surface, that surface becomes covered at about the end of a week by a 
soft, grayish pulp, which consists entirely of embryonic tissue, or a 
mass of embryonic cells, together with some newly-formed bloodves- 
sels. If now a cross-section of the cartilage be made, so as to include 
its whole thickness, together with the wounded surface and the pulp 
covering it, the following appearances will be detected on microscopic 
examination : 1st, in the region farthest removed from the seat of , 
injury, the cartilage-cells, and the hyaline intervening substance in a 
perfectly normal condition ; but on advancing thence gradually to the 
diseased surface, 2d, simple enlargement of the cells and of their nuclei 
and of the cavities in which the cells are contained ; 3d, fissiparous 
multiplication of the enlarged cells and of their nuclei, and the appear- 
ance therefore of several closely-packed nucleated cells in each cavity, 
in which one cell only was originally present — each young cell, more- 
over, being invested in a thin cartilaginous capsule, and so still pre- 
senting the essential characters of a cartilage-cell ; 4th, continued pro- 
liferation — the cells becoming smaller and much more numerous, losing 
their cartilaginous capsules, and assuming all the characters of simple 
embryonic cells, and the cavities containing each group of embryonic 
cells still enlarging at the expense of the hyaline cartilaginous sub- j 
stance, and hence approaching one another and here and there coalesc- 
ing ; 5th, an irregularly-scalloped border, to the whole surface of which 
is attached, and from the whole surface of which grows, the gray film 
of embryonic tissue covering the injured surface of the cartilage — each 
scallop representing a portion of a primitive cartilaginous capsule, the 
cavity of which has come to blend with those around it, and the con- 



1 It is not intended to suggest that these highly-endowed cells are incapable of 
undergoing any form of inflammatory change : for recent observations by M. Char- 
cot seem to prove that the proper cells of the nervous centres may be the primary 
and chief seats of such changes : still less that they take no active part in non- 
inflammatory morbid growth, for the investigations of Dr. Creighton tend to show 
that heterologous growths in the liver commence with vacuolation and internal 
gemmation of the proper* liver-cells. 



EXTRA -VASCULAR PROCESSES. 



49 



Millions embryonic mass representing the united proliferating contents 
of these and other lost cartilage capsules. We thus see the effects of 
injury to have been: 1st, growth and proliferation of the protoplasmic 
or living parts of the cartilage — the newly-formed cells losing grad- 
ually the anatomical and other attributes of cartilage-cells, and de- 
grading into simple embryonic cells ; and, 2d, progressive deliquescence 
and removal of the hyaline or non- vital constituent of the cartilage 
under the influence of this cell-growth and multiplication, culminating 
in its entire disappearance from those parts in which proliferation has 
attained its most advanced stage. 

The mesentery of the adult animal forms, not a uniform lamina, but 
a delicate network, of which the trabecular are in many cases exceed- 
ingly fine, without blood vessels, and consisting solely of a core of con- 
nective tissue, and an investing layer of polygonal tessellated epithe- 
lium. If a little solution of nitrate of silver be injected into the perito- 
neal cavity of such an animal, inflammatory changes take place in that 
epithelium, as they have just been shown to take place under analogous 
circumstances in the cells of cartilage. At the end of about twenty- 
four hours, turbid fluid is found in the serous cavity, the turbidity 
being due to the presence of cellular elements, presenting all varieties 
between ordinary pus-corpuscles on the one hand, and larger cells con- 
taining two or more oval well-defined nuclei on the other; and at the 
surface of the trabecular the epithelial cells are found to have become 
plumper and larger, to have lost their cell-walls, and in many cases 
to have undergone proliferation, giving rise to pus-cells and such other 
forms of cells as are found floating in the peritoneal fluid. The cells 
adhere irregularly to their surface of origin, and are invested, and to 
some degree retained in situ, by bands of coagulated fibrin which has 
exuded from the irritated surface. If no further irritation be excited, 
at the end of a few days the cells floating in the peritoneal fluid become 
opaque and fatty and perish, and those which are still adherent to the 
trabecular begin to flatten and resume the proper characters of serous 
epithelium. 

In the above two cases we have simply proliferation of the cells 
which are proper to the irritated tissues; in the case of the cornea, 
however, the results of irritation are more complex and more remark- 
able. The cornea of the frog consists mainly of a network formed by 
the union of the rays of stellate cells, the meshes of that network being 
occupied by the indifferent non-vital part of the cornea, which corre- 
sponds to the hyaline matrix of cartilage, and to the white fibrous 
trabecular of ordinary connective tissue. If the living cornea be irri- 
tated by the application of a point of nitrate of silver to the centre of 
its area, changes presently take place in it, which soon extend, and 
before long involve the whole extent of its tissue, rendering it more or 
less obviously milky and opaque. The first changes discoverable by 
the microscope are in the immediate vicinity of the spot which has 
been injured. Here the stellate cells first become unusually well- 
defined, and a little more granular or turbid than in health; then 
they get somewhat swollen, their branching processes at the same time 
.thinner; presently these become retracted, and the still growing cells 

4 



50 



INFLAMMATION. 



(somewhat nodulated or botiyoidal in form) as isolated from one 
another in the substance of the corneal matrix, as are the cells of car- 
tilage normally in the cartilaginous matrix. Whilst these changes are 
in progress the cells grow more and more opaque, and their contents 
more and more difficult to distinguish ; but soon, obvious proliferation 
occurs within them, the nucleus divides and subdivides, each such sub- 
division carrying with it its own particular envelope of protoplasm, until 
every corneal cell becomes the mother-cell of an irregular group of em- 
bryonic corpuscles. This increase of the vital elements of the cornea 
is attended, as in the equivalent process in cartilage, by the liquefaction 
and removal of the intervening matrix, and ultimately by the coales- 
cence of neighboring groups of cells and by their discharge from the 
surface of the organ. So far the process is essentially the same as that 
which has been described in the case of cartilage, and indeed with that 
also which takes place in connection with the serous membranes. But 
something more occurs. Whilst the changes above described are going 
on in the centre of the cornea, and spreading gradually from that point 
outwards, other changes are taking place at the periphery of the cornea 
and creeping thence in the centripetal direction. These consist in the 
gradual escape of leucocytes from the now dilated marginal vessels, 
and in their immigration, in virtue of the amoeboid properties which 
they possess, into the interstitial spaces of the adjoining portions of the 
cornea. These spaces they soon crowd, rendering the corneal tissue 
opaque, and soon proliferate, mingling their offspring with those of the 
proliferating corneal cells, from which they become undistinguishable. 
Cohnheim, who first recognized this immigration of leucocytes into the 
inflamed cornea, attributes all the morbid cell-development occurring 
therein to their presence and action, and considers that the proper cor- 
neal cells remain perfectly passive. The active share, however, which 
these latter take in the inflammatory process, has been so often wit- 
nessed and described by competent observers that there can be no 
reasonable ground for doubt upon the matter. The concurrence indeed 
of these two processes, not only in inflammation of the cornea, but in 
the greater number of inflammations (if not in all) seems now to be 
thoroughly well-established. 

Processes, essentially identical with the above, mark the occurrence 
of inflammation in the intervascular spaces of the so-called " vascular" 
tissues ; these are, growth and multiplication of the protoplasmic 
elements, immigration and multiplication of leucocytes, and, concur- 
rently with this overgrowth of the living elements, the liquefaction 
or degeneration, and disappearance, of the non-vital parts and indeed 
of living parts which have attained their highest phase of develop- 
ment. Thus we find the earthy and organic matrix of bone eroded 
into cavities, the trabecule of white fibrous tissue attenuated into a 
comparatively delicate network, and muscular and nervous tissues 
undergoing fatty metamorphosis. 

Vascular Processes. — The condition of the bloodvessels in and about 
an inflamed part has long engaged the attention of pathologists. The 
important share which they take in inflammation is indicated by the 
redness which attends the process, and by the dilatation and throbbing 



VASCULAR PROCESSES. 



51 



of the arteries which lead to the spot in which it is going on. The 
latter fact indeed sustained, if it did not originate, the belief that the 
increased flow of blood to an inflamed part was determined by the 
active movements of the vessels of the part, in the same way that the 
general distribution of the blood is governed by the alternate contrac- 
tions and dilatations of the heart. 

That the active processes, going on outside the vessels in an inflamed 
area, create a demand for an increased supply of nourishment has been 
already pointed out. This demand can only be satisfied through the 
medium of its bloodvessels, which consequently soon dilate, and thus 
attract thither an excessive amount of blood. This change indeed in 
the circulation so speedily follows the effect which calls it into opera- 
tion, that in inflammation produced experimentally it is often the very 
first visible indication of the presence of inflammation. If the web of 
a frog's foot, or its mesentery, or any other convenient tissue of one 
of the lower animals, be irritated, and the processes which follow care- 
fully observed, it will be seen : that generally the small arteries 
included in, and leading to, the irritated area, undergo gradual dilata- 
tion and after some hours probably attain their maximum diameter, 
which may be double that which they originally presented ; that, 
subsequently to the commencement of the arterial dilatation, perhaps 
some hours afterwards, the capillaries and veins of the part follow 
suit ; and that thus at length all the vessels of the affected area and its 
neighborhood become proportionately enlarged ; it will further be seen 
that, while these changes of dimension are going on in the vessels, 
equally remarkable changes are going on in the blood-stream within 
them. At first, while the arteries only are affected, the rate of flow is 
increased; but, as general dilatation of the vessels supervenes, the 
stream begins to flow more slowly through them (oscillating perhaps 
in some of the capillary vessels), and the white corpuscles congregate 
and cling to the vascular walls ; at length the blood stagnates, and 
losing its serum, the red and white corpuscles become wedged together 
into an apparently homogeneous or amorphous mass. While, how- 
ever, this condition of stasis obtains in the central area of inflammation, 
the vessels immediately around it have become dilated, and through 
them the blood is still circulating with unwonted rapidity. 

It is at the period of stasis, or rather perhaps just previous to it, at 
the time when the white corpuscles or leucocytes are adhering in large 
numbers to the inner surface of the vessels, that that emigration of 
corpuscles, which has been already adverted to, and plays so important 
a part in the inflammatory process, chiefly occurs, and may be best 
observed. If at this time the small veins be narrowly watched (for it is 
in them that the process commences and to them that it is chiefly con- 
fined) small, transparent, button-like bodies will be seen here and there 
to spring from their outer surface; these gradually increase in size and 
number, and assume a pyriform shape, and presently, having acquired 
the form and size of white corpuscles, detach themselves from the sur- 
face from which they seemed to grow, their connection therewith having 
previously been reduced to a mere thread. Prior to their complete 
detachment they often throw out delicate processes which aid them in 



52 



INFLAMMATION. 



their ulterior movements. In this way vast numbers of white corpus- 
cles may pass rapidly in a short time from the interior of the vessels 
into the tissues external to them, without leaving a trace behind them 
of the route by which their escape through the parietes was effected. 

It is obvious from what has been said that variations in the dimen- 
sions of vessels, and variations in the rate of flow of blood through 
them, are very important incidents in the collective phenomena of 
inflammation. But it is not at all easy to determine upon what cause, 
or on what combination of causes, each such variation in different cases 
depends. And especially it is difficult to trace the exact relation 
between the varying diameters of vessels and the varying rates of the 
passage of their contents along them. We know that the smaller 
arteries and veins (the arteries more prominently) are capable of con- 
tracting and dilating within comparatively wide limits, and thus of 
regulating to a considerable extent the amount of blood to be admitted 
into, or discharged from, the area to which they minister ; and that 
this function is effected by means of their muscular walls, which, when 
they contract, diminish the calibre of the vessels, when they relax, 
permit of their passive dilatation. We know also now, chiefly through 
the labors of Strieker, that the capillary vessels are not merely passive 
organs, contracting and dilating in obedience to the various degrees of 
blood-pressure to which they are subjected; but that they also possess, 
in virtue of the endowments of the living protoplasm of their walls, 
like the arteries and veins, a power of active contraction. And we 
have further now good reason to believe that arteries, veins, and 
capillaries possess, in addition to the power of active contraction and 
the capability of passive dilatation, a distinct power of active dilatation, 
which is attended not only with increase of diameter, but with increase 
of length. Again, we know that the muscular tissue of the vascular 
system, like that of all other parts, is under the dominance of nerves — 
in this case the nerves of the vaso-motor system. Contraction of vessels 
may be caused, either by the direct application of irritants to them, or 
by exciting the cut surface of the distal portion of a divided motor 
nerve comprising vaso-motor fibres distributed to them. Active dila- 
tation seems to be specially induced by reflex action, excited by 
stimulating the sensory nerves of the part in or near which the vessels 
which undergo dilatation are situated. Passive dilatation takes place 
whenever the influence of the vaso-motor nerves is removed or weak- 
ened, or when the muscular fibres themselves lose their proper contrac- 
tile power. We may gather from this statement, that the primary 
dilatation of the vessels of inflamed parts is due to reflex stimulation, 
traceable to the inordinately active vital processes which are taking 
place in the extravascular tissues ; and that the later dilatation is 
probably merely passive. As regards the question of the variations 
which take place in the rate of the blood flow in the vessels of inflamed 
parts, it will be sufficient for our purpose to point out that the increase, 
which occurs in the early stage of inflammation in the centre of the 
inflamed area, and which is maintained continuously in the immediate 
neighborhood of the lesion, is in obvious accordance with the physi- 
ological fact that dilatation of the smaller vessels, not only admits of a 



SUPPURATION. 



53 



larger presence of blood in them, but allows of a more ready transit of 
blood along them ; and that the stasis, which takes place after a time 
in the still dilated bloodvessels of the inflamed area, is obviously 
connected with the tendency which the corpuscular elements of the 
blood then acquire to adhere to, and to pass through, the walls of the 
vessels, which conditions themselves doubtless depend on the altered 
nutritive relations then subsisting between the walls of the vessels and 
tissues external to them on the one hand, and the blood within them 
on the other. 

Exudation. — The abundant fluid which exudes from the vessels dur- 
ing inflammation, though consisting essentially of the elements of the 
serum of the blood, presents modifications of constitution according to 
the tissues in connection with which its escape occurs, and further leads 
to different results according to the circumstances attending its exuda- 
tion. The swelling, which always accompanies inflammatory processes 
going on in the substance of organs and tissues, is mainly dependent on 
this serous exudation ; and indeed if the tissues involved be lax, serous 
infiltration or oedema is apt to spread far beyond the limits of actual 
inflammation. In inflammations of mucous surfaces, the mucous mem- 
brane itself, and the tissues which are subjacent to it, all become infil- 
trated, but, in addition, there is generally a copious discharge of fluid 
from the free surface. The most copious discharge, however, occurs into 
serous cavities when the membrane which invests them is the seat of 
inflammation. It is thus that hydro-thorax and ascites are very often 
produced. The fluid which escapes in inflammation is probably never 
identical with the simple blood-serum from which it is derived, but in 
the process of its escape acquires certain modifications of character. 
The most common of these is due to the appearance in it of a compara- 
tively large quantity of fibrin, or fibrinogen. This occurs to a greater 
or less extent in all cases, but is especially remarkable in the inflam- 
mations of serous membranes, in which the great bulk of the exuded 
fibrin coagulates at the moment of its escape, entangling morphological 
elements, and forming the false membrane which adheres so character- 
istically to the serous surface. Another peculiarity is due to the appear- 
ance in it of mucin • this is observed chiefly when the inflammation 
affects mucous and synovial membranes, and is due to the direct influ- 
ence of the cells of the diseased surface. We have pointed out that the 
exudation of white corpuscles is a probably essential element in the 
inflammatory process. A small but variable number of red corpuscles 
are apt to exude in company with these; but at times the escape of 
blood-corpuscles is much more abundant than can be explained by this 
process, and is manifestly due to actual rupture of bloodvessels, gen- 
erally vessels of new formation. 

Suppuration. — A frequent event of inflammation, and one that marks 
one of its recognized stages, is the formation of pus. Laudable pus, as 
it is termed, is a thick, creamy, mawkish-smelling, alkaline fluid, con- 
taining a great abundance of corpuscles, to the presence of which its 
opacity and whiteness are due. The fluid portion, which is termed the 
liquor puris, contains, like the serum of the blood, from which it is 
derived, albumen, salts, etc., and differs little from it in composition. 



54 



INFLAMMATION. 



It sometimes contains also a peculiar albuminoid substance, termed 
pvin. The corpuscular portion consists almost entirely of bodies termed 
pus-cells, which, as generally seen, are globular in form, varying be- 
tween o^oo an ^ Woo i ncn m diameter, and differing little, if at all, 
from leucocytes, or from so-called " mucous corpuscles," or from em- 
bryonic cells. They are transparent, colorless, more or less granular 
masses of protoplasm, without investing membrane ; which, though 
globular when dead or as usually examined, present active amoeboid 
movements of locomotion and change of form, while still living and 
under appropriate circumstances. Under the influence of water, and 
still better under that of dilute acetic acid, the general substance of each 
corpuscle swells up and becomes more transparent, and one nucleus, 
but more frequently two or three or even more nuclei, are revealed 
within it. 

It is obvious, then, that there is little or no microscopical difference 
between typical pus-corpuscles and the corpuscles which have been 
already described as becoming developed, previous to the suppurative 
stage, by proliferation of connective-tissue cells and other stationary 
protoplasmic corpuscles, or by the germination of immigrant leucocytes ; 
and that they both have a common origin. Indeed at every suppurat- 
ing surface the gradual transition of the one into the other may be 
readily observed. There is, however, some season to doubt whether 
pus-corpuscles ever multiply, and some reason to believe that the groups 
of small nuclei they contain are to be regarded as the last abortive 
attempt at reproduction. 

It is not difficult to trace some of the steps which lead to the devel- 
opment of pus. It has already been shown that when inflammatory 
proliferation is going on, the indifferent or non-vital tissues between 
the groups of swarming cells become gradually eroded and removed; 
and that presently, as these disappear, the neighboring groups of cells 
come into direct relation with one another, and thus constitute an 
almost uniform mass of embryonic tissue. They still, however, cohere 
either as epithelial cells do, or through the intervention of some scanty 
adhesive material. It needs only the loss of this cohesive power, and 
the addition of the liquor puris, to convert this inflammatory hyper- 
trophy of tissue into orthodox pus. It is thus indeed that suppuration 
takes place at the surface of an ulcer ; it is thus also that abscesses are 
formed. In the latter case, softening of tissue takes place in the centre 
of some proliferating region ; and the corpuscles which would other- 
wise have formed an ingredient of solid living tissue become changed 
into pus-corpuscles; by extension of the softening, the abscess becomes 
enlarged, and more corpuscles added to its contents ; and then, further, 
the existence of a cavity induces towards it a rapid migration, both of 
the extravasated leucocytes, and of the other embryonic cells which 
crowd the surrounding area. By a continuance of the above processes, 
abscesses approach towards neighboring surfaces, point and presently 
rupture. The pus-corpuscles contained within abscess-cavities speedily 
undergo degenerative changes and perish; they become studded with 
fatty particles, swell, and subsequently break up into a detritus ; or 
they contract and become opaque and angular ; or they undergo calca- 



DESTRUCTIVE PROCESSES. 



55 



reous impregnation. And thus the contents of abscesses become, some- 
times gradually absorbed, sometimes converted into caseous or mortary 
or other such stuff, and a more or less perfect cure ensues. 

Pus of recent formation does not always present the characters which 
have been above assigned to it, but is sometimes thin and watery 
{ichor), sometimes contains a greater or less admixture of blood (sanies), 
and sometimes is attended with much fetor. These obvious peculiari- 
ties are dependent on something special, either in the conditio? of the 
patient or in the part which is suppurating, and are connected with 
peculiarities of microscopical and chemical constitution. Thus, we 
find sometimes, that all the pus-corpuscles have already undergone 
degenerative changes, and that in the place of the orthodox cells we 
have only granule-cells, or it may be a mere molecular debris; some- 
times, that abundant blood-corpuscles are mingled with the other 
elements of pus ; sometimes, that fragments of tissue, bone, and the 
like, are contained in it; and sometimes again, that bacteria and other 
minute living organisms, are present. The admixture of visible parti- 
cles of tissue implies the association of the suppuration with somewhat 
rapid destruction of parts, and often indicates necrosis or gangrene ; 
the presence of bacteria and the like is a proof, either that the pus is 
undergoing putrefaction, or that the blood generally is infected with 
them. Under all these latter conditions fetor is pretty certain to be 
present. 

Destructive Processes. — The destructive effects of inflammation have 
been already adverted to. They are shown in the softening and disin- 
tegration which takes place in the hyaline substance of cartilage, the 
white fibrous element of connective tissue, and the earthy matrix of 
bone, during the gradual multiplication of the cellular elements, and 
especially during the formation of abscesses. They are shown also in 
the fatty and other degenerative processes which go on in muscle, in 
nerve-cells, and other higher tissues, which do not take part in the 
inflammatory proliferation. Destruction occurs, however, in a yet more 
marked form in the various processes termed ulceration and necrosis or 
gangrene. In gangrene a larger or smaller portion of tissue perishes, 
and is probably separated in mass from the neighboring living textures. 
The death of a part is due essentially to deprivation of nourishment, 
which deprivation depends mostly on the obstruction of the arteries 
leading to it, either by the presence of clot in their interior, or by 
thickening of their walls, or by pressure external to them arising from 
accumulation of inflammatory products or from other causes. In 
inflammatory gangrene the parts involved are usually swollen and 
succulent, for the reason mainly that, like all inflamed tissues, they 
have been previously infiltrated with abundant exudation. In ulcera- 
tion the destruction of parts is molecular, or by small fragments, and 
progressive. It has long been a question whether, in the common 
forms of ulcer which undergo gradual extension in area and in depth, 
the evident melting away of tissue, on which their extension depends, 
is due to absorption by the vessels or to discharge from the surface. 
It is obvious in any case that this gradual disappearance of tissue must 
be preceded by its liquefaction, degeneration or death ; for these are the 



56 



INFLAMMATION. 



normal and necessary processes by which, even in health, the worn-oat 
portions of the body are prepared for removal by absorption, and are 
equally the processes by which, during inflammation unattended with 
ulceration, the more lowly-organized structures, the matrix of cartilage, 
of the cornea, of bone, and the like, melt away and disappear; and 
indeed it is impossible to conceive any other. Looking then to the 
fact, that the molecular destruction, which is going on at the surface of 
ulcers, presents no real difference from that which is going on in the 
non-ulcerating stage of inflammation (the products of which are cer- 
tainly in chief measure removed by absorption) it seems not improba- 
ble that a portion of the effete products of ulceration may be also 
removed in this way. But, on the other hand, since the destruction 
takes place at a free surface, which is exuding a considerable quantity 
of fluid, and even of corpusclar elements, conditions which are highly 
favorable to the discharge from that surface of any effete matters which 
are produced there, it seems hardly likely that these should be removed 
by absorption only. Indeed it would seem most probable, on physical 
grounds alone, that the chief removal of ulcerated detritus should be 
effected in the manner last described. That it is mainly thus removed 
is now generally acknowledged. It may be added in confirmation of 
this opinion, that the discharge from ulcers attacking bone contains 
earthy matter, and even small fragments of bone-tissue ; and that gen- 
erally when ulceration is extending rapidly, fragments of disintegrated 
tissue are suspended in the fluids which exude from the ulcerated sur- 
face. In sloughing ulcers, such as those attacked with hospital gan- 
grene, extension is attended with an abundant separation of shreds and 
flakes of dead tissue from the diseased surface. 

It will of course be understood that the above remarks apply only 
to those cases in which ulceration is in progress. Excavations, whether 
termed ulcers or not, in which the surfaces are granulating, are no 
longer examples of ulceration, but of repair and restoration. 

Organization and Granulation. — It has already been shown that, at 
an earlier stage than that at which suppuration occurs, the results of 
inflammatory proliferation are the production of a greater or less quan- 
tity of embryonic tissue, or tissue at a low phase of organization. 
The intervening materials melt away, and the newly-formed cells come 
into near, if not absolute, relation with one another ; or, if the process 
is occurring at the surface of a serous membrane, the new-formed 
cells are retained in connection with that surface by entanglement 
in the fibrin which undergoes coagulation there. In the progress of 
organization important changes ensue. In the latter case the embry- 
onic corpuscles, entangled in the coagulated fibrin, throw out delicate 
processes, by which they presently unite with one another to form a 
network, in the meshes of which the fibrin is then contained. At 
the same time, new vessels, starting from the normal vessels of the 
subjacent serous membrane, shoot into the adventitious tissue. Later, 
the fibrin undergoes liquefaction and removal, and the interspaces 
between the cells become occupied by a form of white fibrous tissue, 
which they are instrumental in manufacturing. In the case of the 
organization of inflammatory products developed in the substance of 



ORGANIZATION AND GRANULATION. 



57 



; organs, essentially the same series of events happens : the embryonic 
I tissue undergoes conversion into connective-tissue corpuscles, new 
! vessels are formed, the fibrin which has coagulated, and in a greater or 
less degree the proper or special highly-endowed elements of the parts, 
become removed or impaired, and the non-vital elements of connective 
tissue secreted in their place. In both cases, the new-formed tissue 
belongs to the connective-tissue series, and in both tends to become 
contracted and dense and hard in texture. 

The processes, which have been here briefly described, take place 
also in the healing of wounds, and in the filling up of ulcerous or 
other excavations by granulation. Granulations are hemispherical 
masses of cells, produced, and increasing in size, by constant prolifera- 
tion of their own elements and by the immigration of leucocytes. The 
cells in the first instance are purely embryonic in character, and many 
of those at the free surface, and others which migrate thither, become 
shed as pus. But presently they undergo differentiation; the majority 
elongate or send out processes and gradually evolve connective tissue ; 
whilst others also elongate, but become aggregated into solid cylindrical 
loops, and presently converted into hollow channels which communi- 
cate with previously-existing vessels, and thus themselves become 
bloodvessels, and important agents in the further growth and vitality 
of the granulation-tissue. Rindfleisch describes and figures the for- 
mation of lymphatic tissue in the overgrown vegetations of " proud 
flesh." Neighboring granulations tend to run together and to blend, 
and thus cavities become filled with a tolerably homogeneous mass of 
new-formed tissue. But when the granulating mass attains the general 
level of a free surface, such as that of the skin, its further growth 
becomes under ordinary circumstances arrested, epidermis begins to 
shoot from the normal epidermis at the margins over the edges of the 
granulating surface, which at the same time undergoes contraction, 
and soon, if it be of small size, is completely covered. It is even now 
a disputed point as to whether a granulating surface has any power of 
itself to generate epidermic cells. It is certain, however, that the 
chief development of new epidermis begins from old epidermis, that 
very large destructions of surface never become thus covered unless 
aided by artificial means, and that the grafting here and there upon 
such a surface of small fragments of epidermis results in the formation 
of a number of epidermic islets from which new epidermis spreads 
radially. In the healing of a clean cut, of which the edges are placed 
in close apposition, the process is nearly the same as that presented in 
the organization of adhesions. The divided vessels pour out blood 
and serum containing fibrinogen, and this coagulating entangles corpus- 
cular elements, and cements the divided surfaces ; presently the white 
corpuscles thus entangled, and others which migrate into their neigh- 
borhood, emit processes and form a network, which maps out the 
fibrinous cement into comparatively small islets. The further steps of 
the process are identical with those occurring in the organization of 
false membranes. 

The ultimate results of inflammatory organization are generally the 
production of what is commonly termed "cicatricial tissue;" a form of 



58 



INFLAMMATION. 



connective tissue presenting much hardness and compactness, compara- 
tively little vascularity, small and widely scattered plasmatic cells, and 
relatively abundant and dense interstitial substance; which becomes 
bony when developed in connection with bone, and contains fat when 
it replaces normal fatty tissue; but which, while it is capable of repro- 
ducing, with more or less imperfection, the various tissues comprised 
in the connective-tissue group, rarely results in the reproduction or 
development of higher tissues, such as those of muscle, and never prob- 
ably in the formation of organs. Hair and glands, for example, never 
appear in entirely new-formed skin. In some cases the results of in- 
flammatory proliferation are somewhat different. The process becomes 
chronic, cell-proliferation goes on comparatively slowly, and the newly- 
formed tissue, instead of contracting and hardening, becomes swollen 
and perhaps softer than natural, and forms, in fact, an increasing pro- 
jection or lump, in which the cell-elements remain predominant, but 
tend to fatty and other forms of degeneration. Such results are seen in 
keloid and in some forms of arterial atheroma. 

Spread. — The tendency which inflammations have to spread is at least 
as remarkable as that presented by other proliferating affections. If a 
patient has eczema, produced locally by the application of some irritant, 
presently other patches of eczema appear in the neighborhood ; if he 
has a boil, it commences in a point and increases by involving more 
and more of the surrounding tissues, and presently other boils arise in 
the vicinity; in erysipelas and pneumonia, and in inflammations of 
serous and of mucous membranes, the same rule of local spread, or 
spread by simple continuity, is even more obvious. But inflammations 
tend also, in many cases, to spread through the agency of the lym- 
phatics and veins, and thus to involve remote parts, and other tissues 
besides those first affected. Thus suppuration, occurring in a toe or 
finger, is apt soon to be followed by inflammation in the course of the 
lymphatic vessels, and inflammation of the lymphatic glands in the 
groin or axilla ; and indeed generally there is a tendency, if the local 
inflammation be sufficiently intense, for the nearest lymphatic glands 
to become implicated. And thus again, in certain cases, inflammatory 
processes become generalized by means of the circulating blood, so that 
tracts of inflammation, secondary to some primary tract, appear, either 
simultaneously or in quick succession, in various parts of the body. 
Ordinary pysemia furnishes a typical example of this connection; and 
it is not impossible that the frequent association of inflammation in dif- 
ferent organs, and even the invasion of successive joints in acute rheu- 
matism may be similarly explained. 

Constitutional Effects. — We must not forget to consider, however 
briefly, the influences which inflammatory processes going on in some 
part of the system exert on the system generally. We know that pa- 
tients who are suffering from acute inflammations are soon affected with 
febrile symptoms. To wmat are they traceable? In some degree, no 
doubt, to the direct influence which abundant local proliferation of 
tissue exerts upon the nutrition of the system generally. It will be 
recollected, however, on the other hand, that the abundant and active 
proliferation which characterizes the formation of an extensive surface 



VARIETIES. 59 

of granulations, or the development of the foetus, produces no such con- 
stitutional disturbance. But indeed the inordinate consumption of 
nutrient matter is certainly not the main cause of the constitutional 
symptoms of inflammation. It has been proved by direct observation 
that a part generates heat much more powerfully when it is inflamed 
than it does when it is in its normal state; and that the blood in the 
veins coming from an inflamed area is distinctly hotter than the blood 
which is brought thither by the arteries. It is certain, therefore, that 
a part of the febrile temperature of the system must be due to the dis- 
persion of this excessive locally-produced heat. Again, as we have 
already pointed out, wherever inflammatory proliferation is active, there 
also the processes of effusion from the bloodvessels, of molecular disin- 
tegration, and of lymphatic absorption are specially active. And we 
thus find that large quantities of modified nutrient fluid, and of prod- 
ucts of decay, are alike being constantly removed from the seat of 
disease and poured through the thoracic duct into the systemic veins. 
It seems highly probable that here is the source of the comparatively 
large amount of fibrinogen which is so characteristic a feature of the 
blood of inflammation, and that here is also the main source of the ex- 
cess of urea and other products of retrograde metamorphosis, which are 
presently discharged by the various emunctories. There can be no 
doubt that the general symptoms of inflammatory fever must be largely 
due to the heightened temperature, and to the alteration and deteriora- 
tion of the blood which have been thus produced — conditions which, 
according to their amount, must necessarily influence in a greater or 
less degree the nutrition and the functions of all parts of the system. 
It is certain too that the nervous system, mainly by its vaso-motor 
branches, plays an important part in the production of febrile disturb- 
ance, though what that part is is not so easy to identify ; and that the 
symptoms of inflammatory fever are largely modified, chiefly in the 
way of complication, by the interpolation of other symptoms due to the 
modification, impairment, or destruction of the normal functions of the 
organ which happens to be affected. 

Varieties. — In the foregoing pages we have discussed the phenomena 
of inflammation in the abstract ; our account of inflammation would 
scarcely, however, be complete if we failed to point out some of the 
varieties which inflammation presents — varieties which depend, partly 
on the intensity of the process, partly on the nature of the organ impli- 
cated, and partly on the nature and mode of operation of the cause ; 
and reveal themselves as such, either by their extent and arrangement, 
or their tendency of result, or their duration. It need scarcely perhaps 
be pointed out that we trench here upon the domain of specific diseases, 
or diseases in which the inflammation is a mere secondary phenomenon, 
excited and kept up by the operation of some specific irritant, which 
has been received into the system and then distributed through it. 
But indeed, as knowledge advances, we see more and more clearly that, 
in every case of inflammation which comes before us, the inflammation 
has been excited by some cause which imparts to it certain distinctive 
features — that it is in truth specific — and we recognize the fact, half 
unconsciously perhaps, by distinguishing most varieties of inflamma- 



60 



INFLAMMATION. 



tion by specific Dames. 1. Varieties as to extent and arrangement. In 
many cases, inflammation pervades, with tolerable uniformity, the whole 
of an organ or tissue — such is the case in pneumonia, in peritonitis, in 
ervsipelas, and pityriasis rubra; in many cases it is irregularly dis- 
tributed in patches or groups, as we see in the rashes of typhus and en- 
teric fevers, in urticaria, in shingles, and in lobular pneumonia; in 
others again, it assumes certain definite patterns — disks in lepra, rings 
in erythema circinatum and in ringworm, crescents in measles, and 
sinuous bands in some cases of secondary syphilis. 2. Varieties as to 
tendency of result end intensity. It is certainly a striking fact, that some 
forms of inflammation, no matter how severe they may seem to threaten 
to be, never pass beyond the earlier stages of the process; while others, 
which commence probably with the mildest indications, invariably go 
on to suppuration or gangrene. In such diseases as measles, pityriasis, 
and lepra, the local phenomena of inflammation are always exceedinglv 
slight, and consist in little more than hyperemia in patches, followed 
by modification, and then detachment, of the overlying epidermis. In 
urticaria, the process, if more intense for the time, is far shorter in its 
duration; for here we get pretty intense congestion, with rapid effusion 
of serum into the congested tissues, which subsides in a few hours or 
even in a few minutes, and is rarely followed by desquamation. In 
eczema, in herpes, and in pemphigus, the local congestion is always 
attended with abundant effusion of serum beneath the epidermis. Now, 
in all the above cases, notwithstanding the marked differences of detail 
which thev exhibit, the changes are rung onlv on mere congestion and 
effusion, together with (as of course is always the case) a certain amount 
of nutritive change, if not of actual proliferation. In other cases, sup- 
puration seems to occur almost invariably; it is so with small-pox and 
cow-pox and the affections known as impetigo and ecthyma; and in 
inflammation affecting the periosteum, and the womb immediately after 
parturition, this suppurative tendency is extremely well marked. In 
other cases, again, the tendency of the inflammation to end in the death 
of tissues, that is, in ulceration or gangrene, is a characteristic feature; 
as examples of this tendency we may adduce erysipelas, carbuncle, and 
hospital gangrene. 3. Varieties as to duration. Inflammations are 
acute or chronic in their progress. Acute inflammations are sometimes, 
as in factitious urticaria, remarkably evanescent. Chronic inflamma- 
tions are chronic in different fashions. In some instances the inflam- 
matory process, as in the case of a patch of psoriasis on one of the knees, 
or in that of a sinus which is constantly discharging pus, is continuous 
and of long duration. In a larger number of cases, however, chron- 
icity is due to a succession of acute attacks, each one of which may have 
but little intensity. It is thus that urticaria assumes the chronic form 
of urticaria evanida, and that erysipelas and eczema become perpetu- 
ated; we may add to the list rheumatism and gout. It seems probable 
also that cirrhosis of the liver, referable to alcohol, is rendered chronic 
by the repeated irritation induced by the repeated application of the 
alcoholic poison. It is in these latter forms of chronic inflammation, 
more especially, that the proliferation of tissue, which attends all in- 
flammation, becomes permanent, and leads to a substantial addition to 



CLASSIFICATION OF TUMORS. 



61 



the normal bulk of a part; that bones become increased in thickness 
and in density; and that the interstitial tissue of the liver, kidneys, 
lungs, and nervous centres becomes augmented in quantity, and by its 
augmentation leads to the gradual destruction of the essential glandular 
elements. 

Classification of Tumors. 

It would be foreign to the purpose of this work, and to a great ex- 
tent out of place, to enter into anything like a minute account of the 
various forms of tumors which are described by pathologists. We 
propose, however, to pass them generally in brief review, describing at 
greater length those of them which have a special relation to the prac- 
tice of medicine, and a special interest therefore for the physician. 
Tumors, in the proper sense of the term, that is, morbid proliferating 
growths, or neoplasms, have a very close affinity with simple hyper- 
trophy or hyperplasia on the one hand, and with mere inflammatory 
overgrowth on the other. Tumors are in fact in many cases, structu- 
rally considered, a simple hyperplasia or overgrowth of normal tissue, 
differing from true hyperplasia however in the facts — first, that they 
are overgrowths originating in a limited area; and, second, that their 
growth has no relation to the general growth of the tissue out of which 
they spring, or to the general nutrition of the body. In many cases, 
again, tumors and simple inflammatory overgrowths are structurally 
identical ; generally, how T ever, inflammatory formations are much more 
rapid in growth than tumors are, and at the same time, much more 
ephemeral in their duration. 

Tumors have been variously classified. Sometimes they have been 
divided into the tw r o large groups of cystic and solid tumors. But 
cysts, although a very characteristic feature of some new formations, 
are for the most part merely incidental to them, and their presence or 
absence can in no sense furnish the basis of a scientific classification. 
Sometimes, again, they have been distinguished into those which are 
innocent and those which are malignant. It need scarcely be said, that 
the question as to the malignancy or non-malignancy of a tumor is 
always, in a practical point of view, a question of supreme interest ; and, 
further, it may be admitted that, in a large number of cases, malignancy 
is linked to special structural characteristics, and hence may be pre- 
dicted from them. But, on the other hand, it is now generally admit- 
ted that malignancy varies in degree, and that few if any proliferating 
growths are wholly free from liability to assume malignant properties. 
Virchow, accepting the law which J. Miiller enunciated, namely, that 
" the tissue wmich constitutes a tumor has its type in one of the tissues 
of the organism, either in its embryonic condition or at the period of 
its complete development," classifies tumors according to their struc- 
tural relations with the normal tissues of the body. Such a classifica- 
tion is at once scientific and intelligible; and although many difficulties, 
and much room for difference of opinion, present themselves when it is 
attempted to carry it out in detail, there can be little doubt that in 
principle it is sound, and will ultimately be universally adopted. But, 



62 



TUMORS. 



admitting that all tumors have their type in the normal tissues, it does 
not always happen that a tumor has its type in the very tissue in which 
it originates. "When a tumor arises in a tissue from which it takes its 
own pattern, it is regarded by Virchow as being " homologous when, 
on the other hand, it becomes developed in a tissue which it does not 
thus resemble, it is termed by him " heterologous." The latter term 
has often been 6 used of malignant tumors, in the belief that they are 
something altogether different and distinct from the normal elements of 
the body, something in fact of the nature of parasites • and it is well 
to know that, even in the more accurate and limited sense in which 
Virchow employs it, it still carries with it the sense of malignancy. 
Most malignant tumors are heterologous. 

Virchow divides tumors into four groups, as follows : 1, tumors 
formed at the expense of the elements of the blood, or tumors by ex- 
travasation and exudation; 2, tumors formed by the retention of prod- 
ucts of secretion, and by the dilatation of ducts and cavities; 3, tumors 
originating in proliferation of tissues (these he subdivides into (a), his- 
tioid tumors, which are formed out of a single tissue ; (6), organoid, 
which are characterized by greater complexity and an approach to the 
structure of organs ; and (c) teratoid, in which a combination of organs 
exists); and 4, or lastly, complex tumors, in which two or more tumors 
of the foregoing groups are combined. The first two of Virchow's 
groups embrace a series of pathological results which can only conven- 
tionally be regarded as tumors; all true tumors are included in his 3d 
and 4th groups. 

We shall not discuss the details of the above classification, nor shall 
we reproduce here the convenient modification of it which. MM. Cornil 
and Ranvier have published ; yet, in the brief account of tumors which 
we are about to give, we shall be guided in a very great degree by the 
views of these authorities. Indeed the modifications, mainly of arrange- 
ment and proportion, which we shall introduce, will have reference 
almost entirely to convenience of description and to clinical considera- 
tions. We shall arrange tumors (omitting, as will be observed, all 
further reference to the teratoid and complex forms) in the following 
groups : 

1st group, tumors which have their type in the various forms of 
connective tissue; this includes the fibrous tumor or fibroma, the fatty 
tumor or lipoma, the mucous-tissue tumor or myxoma, and one or two 
less important varieties ; 

2d group, tumors composed of cartilaginous tissue, or chon- 
dromata; 

3d group, osseous tumors, or osteomata; 
4th group, tumors formed of nervous tissue, neuromata; 
5th group, tumors consisting of muscular tissue, myomata; 
6th group, vascular tumors, or angiomata; 
7th group, tumors consisting of lymphatic tissue, lymphomata ; 
8th group, tubercle and granuloma, including syphilitic gummata, 
and farcy ; 

9th group, sarcomata, or tumors which resemble embryonic tissue ; 
10th group, tumors presenting an alveolated structure, the alveoli 



CONNECTIVE -TISSUE TUMORS. 



63 



being formed of connective tissue, and occupied or lined by closely 
packed epithelium-Ilk^ cells. All these are embraced in the general 
term carcinoma. 

Group 1. — Connective-Tissue Tumors. 

1. Fibrous Tumor, or Fibroma. — Tumors of this kind consist essen- 
tially of connective tissue, that is of a network of plasmatic cells, sep- 
arated from one another by bundles of white fibrous tissue and a variable 
proportion of elastic fibres — the latter, indeed, are often absent. They 
are rosy, grayish, yellowish, or white in tint ; are sometimes dense and 
close-grained like fibro-cartilage, sometimes soft, loose in texture, and 
succulent ; are provided for the most part with scanty and small blood- 
vessels, and are sometimes non-vascular; and very often, when involving 
a mucous or a serous surface, involve also the glandular and papillary 
structures, which then undergo hypertrophy. Fibrous tumors often 
originate in the subcutaneous connective tissue; often too in the. sub- 
stance of the skin, producing sometimes warts or papillomata, some- 
times "molluscous" tumors, and sometimes pedunculated masses of 
enormous bulk. Again, they very frequently become developed in 
connection with mucous surfaces, and then form mucous polypi. The 
opaque cartilage-like patches often seen on the surface of the spleen, 
heart, and other viscera, are fibromata ; but the plasmatic cells are 
scanty, indistinct, and much flattened, the fibrillated intermediate sub- 
stance is very densely stratified, and they are without vessels. The 
thickening and induration of the skin and subcutaneous connective 
tissue, which attend elephantiasis Arabum, are chiefly due to the growth 
of connective tissue, and constitute a diffused form of fibroma. It is 
very difficult to separate, by any hard and fast line, the results of chronic 
inflammation from fibromatous tumors, especially from the diffused 
forms of fibroma. And, indeed, we know, that very frequently, papil- 
lary growths and polypi are a mere sequel to ordinary inflammatory 
processes ; and that there is little if any real difference between the 
forms of fibroma involving the pyloric extremity of the stomach, or 
the substance of the mamma, which we generally regard as of the na- 
ture of tumors, and the fibrous growth invading the liver in cirrhosis, 
which we commonly consider to be simply inflammatory. Fibrous 
tumors are apt to undergo various forms of degeneration, and especially, 
the fatty, the mucous, and the calcareous. They are almost invariably 
quite free from malignant tendency. 

2. Fatty Tumor, or Lipoma. — Fat is a mere modification of connective 
tissue, in which the plasmatic cells have become the seat of fatty 
deposit, and so much distended therewith that their protoplasm and 
nuclei can only be recognized with difficulty, and they themselves are 
transformed into globular, or (from mutual pressure) polyhedral, 
bodies. Fatty tumors consist, for the most part, simply of newly- 
developed fat-tissue, and present little, if any, structural differences 
from normal fat. They vary very much in size, and are generally 
lobulated, and capable of pretty easy enucleation from the tissues in 
which they are imbedded; sometimes, on the other hand, their limits 



64 



TUMORS. 



are ill-defined, and they pass gradually into the normal textures. 
Lipomata often originate in the subcutaneous connective tissue, and 
occasionally in the submucous and subserous tissues ; also in the neigh- 
borhood of glandular organs ; and indeed generally wherever fat exists 
naturally. Not ur.frequently they form polypi or pedunculated tu- 
mors. There are several well-defined varieties of fatty tumors ; one, 
which may be called fibrous lipoma, is characterized by the presence of 
abundance of fibrous tissue ; another is the myxomatous lipoma, in 
which the characters of myxoma and those of lipoma are blended ; a 
third is the cystic lipoma; and the last which we may enumerate is 
the erectile or cavernous. Further, lipomata, like fibrous tnmors (to 
which they are closely related), are liable to undergo calcareous and 
other forms of degeneration. They are probably always innocent. 

3. 3Iucous Tumor, or Myxoma. — Mucous tissue, which is common 
in the fbetas, exists permanently in the vitreous humor only. The 
tissue of the umbilical cord furnishes a typical example of it. It con- 
sists of plasmatic cells, which are generally stellate like those of con- 
nective tissue or of bone, and of an intercellular substance, which, 
instead of being solid, as in these latter cases, is transparent and fluid 
and contains mucin, or the characteristic constituent of mucus. Myx- 
omata are lobulated tumors, gelatinous in consistence, translucent, and 
yielding a transparent, glairy, never milky fluid. Under the micro- 
scope they are seen to consist of scattered cells, sometimes round or 
oval, often stellate, and an abundant network of capillary vessels, sepa- 
rated from one another by the structureless fluid, or semifluid, mucus 
which gives them their specific character. They vary in color and 
consistence, according to the relative proportions of cells and mucus 
which they contain, being more opaque and denser as the cellular 
element predominates. They originate in most places in which normal 
fat occurs, and indeed there seems to be some definite relation between 
them and fat. They occur, however, elsewhere. Their most common 
seats are, the subcutaneous and submucous tissues, and the connective 
tissue between muscles. They are not unfrequently met with in the 
brain and in the course of nerves, in glandular organs — the breast and 
kidney — and beneath the periosteum. In connection with the skin 
and mucous membranes, they often form papillary or polypoid out- 
growths. Placental hydatids are a good example of this latter variety. 
Myxomatous tumors sometimes contain cavities {cystic myxoma), some- 
times their cells become distended with fat (lipomatous myxoma), some- 
times the intercellular mucous fluid tends to condense and become car- 
tilaginous (enchondromatous myxoma), and sometimes again the vessels 
are very abundant and large (vascular or erectile myxoma). Myxomata, 
when not occurring in situations where fat is a normal element, must 
be regarded as heterologous, and then occasionally present malignant 
characters. Generally, however, they are innocent, and do not even 
return after removal. 

4. Glue-like Tumor, or Glioma. — This is a form of tumor which, 
according to Y T irchow, consists of connective tissue resembling that of 
the nervous centres ; and is in fact a growth, which originates almost 
exclusively in these centres, in connection with nerves, and in the retina. 



CARTILAGINOUS TUMORS. 



65 



The neuroglia consists of veiy small and delicate cells, imbedded in a 
finely granular or amorphous substance. These have a tendency to be 
stellate, and, in carefully prepared sections, appear to unite with one 
another by their rays, so as to map out the intervening substance into 
small polygonal area?. Gliomatous tumors present the like structure, 
and are generally white and medulla-like in aspect, and exceedingly soft. 
They vary no doubt considerably, in respect of the relative proportions 
of their cellular and intercellular elements, in their tint, consistence, 
and vascularity ; and run, on the one hand, into myxoma, on the other 
into the small round-celled variety of sarcoma, with one or other of 
which it is difficult to avoid confounding them. They are apt to 
undergo mucous, caseous, or fatty degeneration, and to become cystic. 
The situations which these tumors affect, and the tendency they have 
to attain a large size, render them dangerous; but they are rarely 
malignant. 

Group 2. — Cartilaginous Tumors, or Chondromata. 

Chondromata consists of cartilaginous tissue, that is, of cells sur- 
rounded by lamellated thickenings, and separated from one another by 
intercellular substance yielding chondrin, which is generally hyaline, 
as in ordinary articular cartilage, but may be reticulated as in yellow 
cartilage, or fibrous as in fibro-cartilage. Cartilaginous tumors have 
for the most part a slightly translucent or pearly aspect, and a whitish, 
grayish, or yellowish hue. They vary greatly in consistence, being 
sometimes dense and hard and crisp, sometimes forming a diffluent 
pulp. They are generally distinctly lobulated, the lobules being sepa- 
rated by connective tissue, which conveys the vessels that nourish 
them ; for the cartilaginous tissue itself is entirely extra vascular. The 
tumors are often perfectly well-defined ; but are sometimes irregularly 
diffused through the tissues or organs in which they originate. Under 
the microscope they present many varieties of character. The cells 
vary in size and abundance, but are always encapsuled ; they are 
generally round or oval, but occasionally branched or stellate like those 
of the cornea ; further, they not unfrequently undergo fatty or calca- 
reous degeneration. The intercellular substance, which, as previously 
stated, may be hyaline in character, or consist in part of either white 
fibrous tissue or elastic fibres, becomes sometimes softened into a 
mucous fluid In which the cartilage-cells are simply suspended. Chon- 
dromata in this latter condition have a resemblance to the intervertebral 
cartilages; and it is by such softening in patches that they become 
cystic. Virchow divides chondromata into ecchondroses and enchon- 
i dromata. The former are merely outgrowths from the normal cartilages, 
i and are therefore homologous; they never attain important dimensions, 
t are invariably innocent, and very apt to be converted into true bone, 
j The most interesting examples of ecchondrosis are furnished by the 
j cartilaginous outgrowths, which take place in joints affected with 
' chronic rheumatoid arthritis. Enchondromata are heterologous. They 
occur most frequently in bones, and especially in the long bones ; but 
.they are met with also in the subcutaneous connective tissue, and in 

5 



66 TUMORS. 

the aponeuroses, in the lungs, parotids, testicles, ovaries, and mammary , 
glands. Enchondromata are no doubt generally innocent ; but they , 
are certainly sometimes distinctly malignant, and may be traced along 
the lymphatic vessels, involving lymphatic glands, and ultimately 
invading remote organs. 

Group 3. — Osseous Tumors, or Osteomata. 

Osteomata are generally divided into three species — ivory osteomata, 
compact osteomata, and spongy osteomata. The first species is met 
with on the inner surface of the skull, and at the joint-ends of bones 
and elsewhere ; it is characterized by remarkable compactness of tissue, 
and under the microscope presents bone-corpuscles and canaliculi 
(which latter run radially to the surface), and a total absence, or great 
deficiency, of Haversian canals, and hence of vessels. Compact oste- 
omata present the ordinary characters of compact bone. Spongy 
osteomata, as their name implies, resemble more or less closely the 
spongy or cancellous tissue. Osteomata spring sometimes from the 
surfaces of bones, and are then termed exostoses ; sometimes they origi- 
nate in the substance of bones, and may then be named enostoses ; and 
in both of these cases are clearly homologous. They are sometimes, 
however, heteroplastic. Thus, they appear in the connective tissue, in 
the membranes of the brain and cord, in the brain itself, in the choroid 
and vitreous humor of the eye, in the lungs and in the skin. True 
osseous tumors, even when heteroplastic, are probably never malignant. 
Nevertheless tumors, which have undergone more or less perfect 
conversion into true bone, are sometimes malignant in a very high 
degree. These are tumors, however, which are made up in consider- 
able measure of cartilaginous or embryonic tissue, and should probably 
be regarded as chondromata or sarcomata which have undergone cal- 
careous or osseous transformation. 

The teeth occasionally present outgrowths of their own tissue, which 
have been named odontomata. 

Group 4. — Nervous Tumors, or Neuromata. 

The term " neuroma " has been often loosely applied to all tumors 
occurring in the course of nerves ; and thus myxomatous and fibrous 
and various other tumors have been, to a large extent, regarded as 
varieties of neuroma. Neuroma, in the strict sense of the word, means 
a tumor formed essentially of nervous tissue, either vesicular like that 
of the ganglia or central nervous organs, or fasciculated like that of j 
the nerves or medullary substance of the brain. The former variety 
is exceedingly rare, but has been described as occurring in the brain 
and spinal cord. The latter variety is more common, but nevertheless 
of unfrequent occurrence, and is met with only in the course of nerves. 
True fasciculated neuromata are generally small white hard tumors, 
occurring singly or in numbers along a nerve-trunk, and more com- 
monly still at the extremities of nerves, which have been divided in 
the amputation of a limb. They are invested and permeated by very t 



VASCULAR TUMORS. 



67 



dense fibrous tissue, the presence of which makes them difficult of 
examination ; but their essential character is, that they contain a large 
amount of newly-developed nerve-fibres, which form an abundant and 
intricate network. The newly-formed fibres have generally the double 
contour ; but neuromata containing pale fibres only have been described. 

Group 5. — Muscular Tumors, or Myomata. 

Striped muscular fibres have been discovered only in congenital 
tumors. Unstriped muscular fibres, on the other hand, are of common 
occurrence in morbid growths. Myomata are most frequently met 
with in the uterus, and it is in connection with the uterus that their 
characters maybe best studied. The so-called "fibrous tumors" of 
this organ, indeed, are, almost without exception, muscular tumors. 
These vary greatly in size, have a reddish or grayish fleshy aspect, 
are generally exceedingly dense, and present a lobulated character 
with curvilinear bands of fibres interlacing with great complexity. 
They always originate within the substance of the muscular walls of 
the uterus, and are, in the early stage, surrounded by uterine muscular 
tissue; but if seated near either the mucous or the serous surface, they 
are apt to protrude through the fibres which embrace them on that side, 
and presently to become pedunculated. Microscopically, they are found 
to be identical in structure with the uterine muscular walls, containing 
a fully equal proportion of muscular fibres. Further, like the uterine 
walls, they are capable of hardening in contraction, and again of under- 
going relaxation. Moreover, they increase during pregnancy as the 
uterus itself increases, their muscular fibres undergoing similar and 
equal hypertrophy ; and when, after parturition, the uterine walls 
undergo involution they undergo involution also. Uterine muscular 
tumors very frequently suffer degenerative changes; the muscular fibre- 
cells often become fatty ; the tissue is apt to undergo mucous trans- 
formation, considerable patches becoming softened and infiltrated with 
mucous fluid, and not unfrequently converted into cysts; but the most 
frequent and important change is due to the deposition of calcareous 
matter, partly in the connective tissue of the tumor, partly in the 
muscular fibres, by which means at length nearly its whole substance 
may be converted into a hard calcareous mass. This latter form of 
degeneration generally commences in the interior of the tumor; occa- 
sionally, however, it commences at the periphery, and is limited to the 
periphery. Myomata rarely, if ever, originate except in tissues which 
themselves contain muscular fibres. After the uterus, they are most 
frequently met with in the prostate, and in the course of the alimentary 
canal. They have also been found in the scrotum, labia majora, and 
ovary. They are always innocent. 

Group 6. — Vascular Tumors, or Angiomata. 

Several of the tumors which have been already described, and 
several of those which we shall presently discuss, are liable to be ex- 
ceedingly vascular, partly from an excessive formation of bloodvessels, 



68 



TUMORS. 



partly from general and irregular dilatation of bloodvessels, and thus 
to assume an erectile or cavernous character. And indeed, although 
we have adopted the name "angioma" for a group of tumors, there 
are few, if any, tumors in which vascular hypertrophy or hyperplasia 
constitutes the sole, or the essential, characteristic. Angiomata may 
be conveniently divided into two species, in the one of which the 
newly-developed vessels are properly formed arteries, veins, and capil- 
laries, and, in the other of which the blood traverses a series of lacunar 
spaces, like those of erectile organs. The former may be called simple 
angiomata, the latter cavernous angiomata. Simple angiomata are for 
the most part congenital, and form violet or red, more or less elevated, 
patches on the face, neck, and other parts of the surface. Their general 
seat is the skin or subcutaneous connective tissue. In . them the 
capillary vessels are abundant, tortuous, dilated, and often presenting 
irregularities of dilatation, and even pouch-like protrusions. Amongst 
simple angiomata must be reckoned the small racemose knots, which 
often make their appearance on the face and elsewhere, sometimes in 
considerable numbers, and in which the chief morbid phenomenon is i 
dilatation of small arteries and veins. Cavernous angiomata, are known 
also by the name of erectile tumors. They occur in the skin and sub- 
cutaneous connective tissue, in the neighborhood of the external 
mucous orifices, and in some of the internal organs, more especially the 
liver and spleen. They have a spongy character, which is due to the 
comparatively large size of their vascular lacuna?, and the compara- 
tively small amount of solid tissue between them. The lacuna? are 
irregular in size and shape, communicate freely with one another, and 
are lined with a layer of flat epithelial scales. The solid or trabecular 
element consists mainly of connective tissue, in which are sometimes 
contained the ramifications of small vessels, and sometimes unstriped 
muscle. Tumors of this kind are often congenital. Angiomata are ; 
entirely free from malignancy. 

Group 7. — Lymphatic Tumors, or Lymphomata. 

The important relation which subsists between the lymphatic vessels 
and glands, on the one hand, and morbid proliferation of tissue on the 
other, has been already explained. We have shown that, when in- 
flammatory processes are taking place in any part, the nearest lymphatic 
glands tend to become very soon inflamed ; that, if the local inflamma- 
tion has specific characters, the resulting affection of the lymphatic 
glands shares in these characters ; and that, in all cases of malignant 
tumor, it is the neighboring lymphatic glands which, next in order of 
sequence, become the seat of malignant growth. So that, in fact, in 
the morbid proliferations of the lymphatic glands, we have an almost 
complete epitome of the morbid proliferations of the entire organism; 
and to describe the tumors of these bodies would be almost equivalent 
to writing a complete treatise on tumors. What is meant, however, 
by the term lymphatic tumor, or lymphoma, is an actual hypertrophy 
or hyperplasia of lymphatic structure, and the new formation of similar j 
structure in parts where lymphatic organs have normally no existence. I 



LYMPHATIC TUMORS. 



69 



! Under the name " lymphoma" maybe included two perfectly different 
morbid conditions — the one, an abnormal development of lymphatic 
vessels, or lymphangioma; the other, an abnormal development of 

! lymphatic gland-structure, or lymphadenoma. 

1. It is somewhat doubtful if lymphangioma, as an independent mor- 
bid condition, has any existence. There are many cases, however, in 

! which enlargement, and possibly over-development, of lymphatic ves- 
1 sels forms an important ingredient in the morbid conditions which are 
| present. Virchow has shown that, in elephantiasis Arabum, the hy- 
perplastic condition of the connective tissue is largely associated with a 
i dilated and hypertrophic condition of the lymphatic vessels, and espe- 
'■ : cially of the lymphatic spaces in which they originate. This change, 
| however, in the lymphatic vessels seems to be secondary to inflamma- 
I tory obstruction of the lymph-paths through the inflamed lymphatic 
j glands, to which the dilated tubes converge. In congenital hypertro- 
phy of the tongue and lips, the same authority has pointed out the pres- 
| ence of a similar condition of the lymphatic vessels. Further cases 
are occasionally observed in which the penis and scrotum, or corre- 
sponding parts in the female, or the lower part of the abdomen, or the 
thigh or leg are thickened and brawny, and in which groups of de- 
• pressed vesicles appear here and there, and, rupturing, yield a large 
I quantity of pure lymph. Here, the hypertrophic condition of the skin 
I and subjacent parts, and the formation of vesicles, are doubtless all due 
I to dilatation of the lymphatics, and to their distension with lymph — 
conditions which are themselves probably secondary to some proximal 
obstructive disease. 

2. Lymphadenoma. — There are at least three morbid conditions of 
the lymphatic glands which, if w T e have regard to anatomical characters 
only, are extremely difficult, and often impossible, to distinguish from 
one another. These are simple inflammatory hyperplasia, the so-called 
" scrofulous" form of enlargement, and that morbid condition now gen- 
erally known as lymphadenoma, or lympho-sarcoma. 

Simple inflammation of lymphatic glands may be induced by causes 
acting directly upon them, but is much more commonly the result of 
irritation propagated to them along the lymphatic vessels. The glands 
enlarge and become painful, assume a homogeneous aspect and a yel- 
lowish or faint rosy tinge, and under the microscope are found to differ 
but little from glands in the healthy condition — their enlargement 
being due to simple hyperplasia of the cell-elements, or leucocytes, and 
to a greater or less hypertrophy of the reticular connective tissue, in the 
1 meshes of which the proper cells are contained. Lymphatic glands thus 
! affected may suppurate, or undergo other of the changes which are apt 
I to follow on inflammation, but their general tendency is undoubtedly 
| to resolution. The term "scrofulous" is commonly applied to the slow 
| and painless enlargement of groups of lymphatic glands, which occurs 
| for the most part in children, and ends almost invariably in the de- 
| struction of the glands by an imperfect kind of suppuration. These 
; scrofulous glands are generally met with either in the neck, the thorax, 
or the abdomen, and are generally limited to one of these regions only. 
• Indeed, in the neck, where their progress can be best followed, we often 



70 



TUMORS. 



see that the enlargement commences in one gland only; that the glands 
in the vicinity become successively affected, and often after long inter- 
vals ; and that r after awhile, the morbid process ceases with the destruc- 
tion of all the affected glands, the glands on the opposite side of the 
neck remaining all the time perfectly healthy. In the earlier stages of 
this affection, the glands differ little, either to the naked eye or under 
the microscope, from such as are simply hyperplastic from inflamma- 
tion ; but they tend early to become opaque and yellow and friable — 
to undergo caseous degeneration. This degeneration commences in the 
central parts, and gradually involves the whole mass, which presently 
breaks up into a semifluid detritus and thus forms the imperfect pus 
previously adverted to. Occasionally the caseous mass dries up, earthy 
salts are deposited, and the diseased gland becomes an inert earthy con- 
cretion. There is a good deal of vagueness in the sense in which the 
term "scrofulous" is generally employed. It is for the most part taken 
to imply that the morbid process, to which we attach it, is dependent 
on some peculiar condition of the constitution, and further that there 
is some close affinity, if not actual identity, between it and tubercle. 
But the so-called "scrofulous glands" are certainly not tubercular; 
and, although their appearance is sometimes followed by that of tu- 
bercle, in a very large number of cases no such sequence is observed. 
[This opinion is at variance with that expressed by Rindfleisch in his 
recent article on Chronic and Acute Tuberculosis, in Ziemssen's Ency- 
clopedia. In this author's opinion, scrofulous glands are always tuber- 
cular glands. "The grayish parenchyma of a scrofulous gland which 
has not yet become cheesy, is," lie says, "studded not merely with a few 
giant cells, but with a considerable number of veritable tubercules."] 
And as regards cachexia, it is certain that "scrofulous glands" often 
become developed in persons who appear in all other respects in the 
best of health; and further (if we may judge by the limitation of the 
morbid process) that if we admit their dependence on a pre-existing 
state of cachexia, that cachexia must in many cases be limited to a defi- 
nite area or district of the organism. It is well known, however, that 
when a single gland has undergone scrofulous proliferation, there 
is a remarkable tendency for the morbid process to spread thence to 
other glands, in its immediate neighborhood, and thence again to 
others; the disease seems in fact to spread from gland to gland, through 
the agency of some infective material, which the diseased organs evolve. 
It is well known also, that scrofulous enlargement of the glands of the 
neck not unfrequently follows upon diseases of the throat, such as 
mumps, diphtheria, and scarlet fever. Now basing his arguments upon 
such facts as these, Virchow maintains (and we think with reason) that 
scrofulous proliferation of lymphatic glands, like ordinary inflammatory 
hyperplasia of the same organs, is always secondary to some peculiar 
inflammatory process going on at the mucous surface, or some other 
part, which is in distinct relation with them by means of the lymphatic 
vessels; that scrofulous disease of the lymphatic glands of the neck is 
traceable to some inflammatory process going on in the throat, or fauces, 
or contiguous parts; that such disease of the bronchial and mediastinal 
glands is secondary to pulmonary or bronchial inflammation; and that 



LYMPHATIC TUMORS. 



71 



; similar disease of the mesenteric and retroperitoneal glands is the con- 
sequence of inflammatory conditions of the alimentary canal. He con- 
siders that there may be some specific quality or element in the primary 
inflammation, and a similar tendency in its products to undergo rapid 
decay, to that which is characteristic of the morbid products of the dis- 
eased lymphatic glands; but that they are generally not appreciable 
from the fact, that in this case the products are mostly developed at a 
free mucous surface, and are speedily shed from it. But he considers, 
further, that there may be some special aptitude or weakness in the 
lymphatic glands of certain persons, or of certain parts of them, which 
may either be congenital or acquired, and which makes their inflamma- 
tions, induced by indifferent causes, assume the scrofulous character. 

The affection, now generally known as lymphadenoma, differs but 
little anatomically from the morbid lymphatic-gland affections which 
have just been described. It is characterized like them by a simple 
increase of lymphatic tissue, that is, by a development of cells, which 
essentially resemble ordinary leucocytes, in the meshes of a trabecular 
tissue like that of normal lymphatic glands. The cells here, as in 
healthy glands, are so abundant that, in an unprepared section, they 
conceal all other elements; but if they be removed by pencilling or 
washing, the fibrous matrix and vessels come into distinct view. The 
lymphatic glands in lymphadenoma become greatly increased in size, 
in consequence of hyperplasia of their constituents ; they assume for 
the most part an opaque milky appearance, become soft, and yield, as 
carcinoma yields, an abundant milky juice. They tend also to undergo 
fatty and caseous degeneration, and to be the seat of haemorrhage. 
There are two directions in which lymphadenoma tends to produce im- 
portant and characteristic results, — the one by modifying the quality of 
the blood, the other by generalization. 

Lymphadenoma is distinguished remarkably, both from simple in- 
flammation and from scrofulous proliferation of the lymphatic glands, 
by the facts : first, that the morbid process tends pretty rapidly to 
involve the lymphatic glands distributed throughout the organism; 
and, second, that there is a tendency to heterologous development of 
identical morbid gland-tissue in situations in which gland-tissue has 
naturally no existence. In other words, lymphadenoma must be looked 
upon as a variety of malignant disease, in which the secondary as well 
as the primary growths assume the microscopical characters of lym- 
phatic tissue. It should be remarked, however, in the first place, that 
by lymphatic tissue is not meant the whole complicated organism of 
lymphatic glands, but merely that comparatively simple arrangement 
of reticulated fibres and of leucocytes, which is found in the solitary 
intestinal glands, and in the Malpighian bodies of the spleen; and, 
secondly, that the recent investigations of several German physiologists, 
and of Dr. Burdon-Sanderson in this country, have shown that lym- 
phatic tissue is very abundantly distributed throughout the body — 
amongst other places in the subserous tissue, in the submucous layer of 
the intestine, and along the bronchial tubes and the hepatic ducts ; and 
that hence a possibility arises that, notwithstanding the diffusibility of 

. lymphadenoma, its heterologousness and malignancy may, in the strict 



72 



TUMORS. 



sense of these terms, be apparent only. Lyraphaclenoma not unfre- 
quentiv afreets the bronchial and mediastinal glands, and may extend 
thence by continuity, along the connective tissue which invests the 
bronchial tubes, into the substance of the lungs; or may invade the 
substance of the heart, insinuating itself between its muscular fibres, 
without however necessarily forming any distinct tumor. The mesen- 
teric glands also are often chief seats of this disease ; which is then apt 
to transgress the limits of the glands themselves, to invade and distend 
the substance of the mesentery, and to creep thence into the intestinal 
walls, which become consequently thickened in all their layers, and pre- 
sent probably flat tubercular elevations both on the mucous and serous 
surfaces. The liver, the spleen, and the kidneys are also especially liable 
to be the seats of adenoid growth. Here, the morbid growth, as in the 
heart, tends rather to infiltrate the tissues of the organs than to form 
defined and independent tumors. In the fresh condition, the affected 
tracts of these organs present an opaque milky aspect, which may be 
in striking contrast with the surrounding healthy parts, and if they 
abut on the surface probably form a slight convexity there ; moreover 
they probably yield a milky fluid on pressure. When however the 
contrast of color has been impaired or lost by maceration, it is some- 
times impossible by the naked eye alone to distinguish the healthy 
from the diseased parts. In the spleen, the microscopical characters of 
the morbid growth are almost identical with those of the healthy gland- 
tissue; in the liver and kidneys, however, the growth infiltrates the 
texture of the organs, and separates their important elements from one 
another. In the kidneys especially this may be well observed ; for the 
lymphadenoid growth spreads through the intertubular tissue of the 
organs, separating the still healthy tubes and Malpighian bodies from 
one another, until they appear at length to be sparsely distributed in a 
nearly homogeneous mass of adventitious cell-growth. 

The other special characteristic of lymphadenoma is its tendency to 
influence the quality of the blood. Knowing as we now do that the 
lymphatic glands and the spleen, and probably also lymphatic tissue, 
wherever it may be situated, are the laboratories in which the corpus- 
cular elements of the blood are manufactured, and further that they are 
the channels by which, in chief measure, the elements and the products 
of local morbid processes are thrown into the system, we should natur- 
ally expect that anything which impairs or modifies their functions 
would soon lead to impairment or modification of the quality of the 
blood, and then soon to various affections of the general organism. 
The influence of the morbid glands over the constitution of the blood 
in lymphadenoma is, however, quite special. Some years ago now, 
Dr. Hughes Bennett and Professor Virchow almost simultaneously dis- 
covered that in certain cases, in which there was morbid enlargement 
of the lymphatic glands or of the spleen, the circulating blood was 
characterized by containing a comparatively small proportion of red 
corpuscles, and a comparatively large number of leucocytes. These 
observations have since been confirmed and extended by many pathol- 
ogists, and by Professor Virchow himself. And it may now be regarded 
as established that, in the disease under consideration — lymphadenoma 



TUBERCLE. 



73 



! — the blood becomes gradually and permanently deteriorated in quality 
by the addition to it, from the diseased lymphatic glands, of the morbid 
leucocytes which they produce — leucocytes which differ little micro- 
! scopically from those proper to the blood, but which fail to undergo 
conversion into red corpuscles; and that hence the red corpuscles tend 
' to diminish in number, while the white corpuscles tend to accumulate, 
! and finally may, in extreme cases, outnumber the red. This condition 
' of the blood is attended with increasing pallor of that fluid, which 
reveals itself by increasing pallor of the skin and mucous membranes ; 
■ and, from the relative abundance of white corpuscles in it, has received 
i the name of leukaemia or leucocythcemia. Cases in which leucocythsemia 
is present may be divided into three classes : in one the disease pro- 
ducing it is limited to the lymphatic glands; in another it is splenic 
only; and in a third both spleen and lymphatic glands are implicated. 
Virchow distinguishes lymphatic from splenic leucocythsemia by the 
circumstance, that in the former the white corpuscles are generally 
smaller than normal white corpuscles, while they contain for the most 
part solitary and comparatively large nuclei; whereas in the splenic 
form of the disease, the leucocytes more closely resemble those of the 
normal blood, being equally large with them, and containing generally 
two or more nuclei of small size, which become obvious under the in- 
fluence of acetic acid. When the spleen and lymphatic glands are both 
affected, both varieties of leucocytes may be discovered mingled in the 
blood. Lymphadenoma may, however, exist without producing leu- 
cocythsemia. [When an enlargement of the spleen and of the glands 
exists without any increase in the number of the white blood-corpuscles, 
the condition is called pseudo-leukaemia, of which, as in the true form 
of the disease, there are three varieties. In the first variety, the glands 
are alone affected ; in the second, the spleen ; and in the third, both 
glands and spleen.] 

Group 8. — Tubercle and Granuloma. 

The latter term has been employed by Virchow to include the specific 
growths of syphilis, lupus, elephantiasis Grsecorum, and farcy, because 
anatomically they differ but little from ordinary granulation-tissue, and 
it is difficult often from mere inspection to decide whether such growths 
are tumors or mere inflammatory products. Tubercle he regards as 
a species of lymphoma ; and many pathologists are of the same opinion. 
It is by no means improbable that they are right, and certainly very 
weighty arguments may be adduced in favor of this view. On the other 
hand, many good observers by no means admit the adenomatous na- 
ture of tubercle. And since, therefore, it is generally acknowledged 
to be closely allied to gummata and to the tubercles of farcy, it seems 
reasonable to classify it, at all events provisionally, with these latter 
affections. 

1. Tubercle. — From the time of Laennec up to within a very recent 
period, tubercle was regarded as a mere exudation or deposit from the 
blood, consisting no doubt in large measure of cells, but of cells which 
were degenerate from the beginning and never had any vitality ; and 



74 



TUMORS. 



it was recognized as occurring in two forms, — one, the gray granula- 
tions or miliary tubercles (hard, grayish, translucent bodies, varying 
from the size of a small pea downwards, and tending to become opaque, 
yellow, and soft or friable internally) ; the other, the so-called " crude" 
tubercles, which are generally of larger size, of a nearly uniform opaque 
buff color, friable or cheese-like in consistence, but which were com- 
monly believed to take their origin in the general caseous conversion of 
gray tubercles, and to represent therefore a comparatively late stage of 
the tubercular process. It is now, however, generally admitted, that 
tubercle is no mere deposit, but on the contrary, a living growth (as 
much as sarcoma and carcinoma are living growths) consisting essen- 
tially of cells, but having, above all other growths, a tendency to 
undergo rapid degeneration and death, and especially that form of 
degeneration which is termed caseation, and will later on be more par- 
ticularly described ; that the gray semi-transparent material which 
forms the whole bulk of miliary granulations, and which may often be 
recognized at the periphery of large masses, is alone living and grow- 
ing tubercle; and that the yellow caseous substance which has fre- 
quently been taken for the essential part of tubercle is merely effete and 
dead matter, often no doubt tubercular in its origin, but often also the 
detritus of quite other kinds of proliferating growths. 

Gray granulations take their origin in the connective web of most 
organs and of many tissues, and, as will presently be shown, not im- 
probably affect specially the elements of the lymphatic tissue which is 
distributed throughout the organism. They are common in serous 
membranes and in the pia mater, and it is here probably that their 
development may be best studied. If a minute tubercle from one of 
these situations be placed under the microscope, it will be found to 
consist mainly of an aggregation of cells, mostly of small size and of 
the embryonic character, of which those towards the centre will prob- 
ably even now be angular, withered, and opaque from granular fatty 
deposit. A close examination will reveal other facts : the growth will 
almost certainly be found to have taken place in connection with some 
minute vessel, probably to encircle it ; and again, beyond the margins 
of what may perhaps be regarded as the actual growth, a zone of con- 
nective tissue will be recognized in which hypertrophy and prolifera- 
tion are commencing — the plasmatic cells being larger than those of 
the normal tissue, and containing in many instances in their interior 
broods of two, three, or more secondary cells. It would seem, there- 
fore, that the morbid process commences with proliferation of the con- 
nective-tissue elements of the adventitia or outer wall of bloodvessels, 
and that it gradually involves more and more of the neighboring con- 
nective tissue ; and that as it spreads at the margins the central parts 
rapidly fall into decay. It follows that the chief microscopic elements 
of tubercle are: first, simply enlarged connective-tissue corpuscles (fusi- 
form and stellate) ; second, these same cells containing two or more new 
cells within them ; and third (and probably far most abundantly), small 
shrivelled granular embryonic corpuscles. It should be added, that 
new bloodvessels never seem to become developed in the tubercular 
process, that no higher stage of development, in fact, than the mere 



TUBERCLE. 



75 



over-production of new cells of a low grade of organization is ever 
attained, and further, that the vessels around which tubercles form 
become at a very early period obstructed by the coagulation of fibrin, 
j and the accumulation of leucocytes in their interior. The intercellular 
substance of tubercle is, in the first instance, that of the particular form 
! of connective tissue in which it originates; it soon, however, becomes 
j scanty and indistinctly fibrous or granular. Rindfleisch has described 
i in tubercle a reticulated connective tissue, in the meshes of which the 
| corpuscular elements are contained — an arrangement, in fact, almost 
! identical with that which obtains in adenoid tissue, and which, if gen- 
I erally present, goes far to confirm the views of those, who regard tu- 
bercle as a development of adenoid tissue. It is generally, however, 
extremely difficult to satisfy oneself of the presence of any such fibrous 
stroma, and MM. Cornil and Ranvier distinctly deny its presence. 
They admit that a kind of reticulum, probably of artificial production, 
may be recognized in sections which have been hardened with chromic 
acid or with alcohol ; but they assert that it never contains protoplasmic 
particles (as lymphatic stroma does), at the points whence the fibres of 
the network diverge, and moreover that in the unprepared tubercle it 
has no visible existence. 

But even if tubercular growths be not, like lymphadenomatous tu- 
mors, mere overgrowths or reproductions of modified lymphatic gland 
structure, there can be no doubt at all that they are in very large pro- 
portion adventitious growths originating in lymphoid tissue. At all 
events, many physiologists, and more particularly Dr. Sanderson, have 
shown satisfactorily that lymphatic gland or adenoid tissue is far more 
generally distributed throughout the body than was formerly suspected, 
and that it is especially abundant in all those parts in which tubercle 
is most frequently developed ; and indeed, as regards tubercles pro- 
duced experimentally, Dr. Sanderson seems clearly to have demon- 
strated their origin in hyperplasia of these normal lymphatic accumu- 
lations. We need hardly quote, in favor of this doctrine, the fact of 
the frequent development of tubercle in the lymphatic tissue of the 
solitary and agminated glands of the intestines, and in that of the 
spleen and lymphatic glands. We will discuss, however, two cases, 
which Dr. Sanderson has specially investigated, in the course of his 
experiments on the artificial production of tubercle. In the first place, 
he has shown that in the peritoneum, as indeed in all serous mem- 
branes, small masses of adenoid tissue are abundantly distributed, in 
some cases unconnected with vessels, but more commonly adherent to 
their walls, or encircling them, or even investing whole groups of capil- 
lary vessels ; he has also shown that, in animals dead of acute perito- 
nitis, all these masses become soft, tumid, and enlarged; and further 
that, when tuberculosis is in progress, it is in them and by the multi- 
plication of their cells, rather than by that of connective-tissue corpus- 
cles, that miliary tubercles gradually become developed. Secondly, as 
regards the lung, it is now generally held that gray tubercles originate 
in the matrix of the organ, and not, as was formerly believed, within 
the air-cells ; and it is generally admitted, we believe, that the locality 
which they chiefly affect is the connective tissue which surrounds the 



76 



TUMORS. 



bronchioles at the point at which these lose themselves in the air-cells, 
and that the growth of tubercle-cells gradually extends thence into the 
substance of the tissue, which separates the air-cells from one another, 
and of that which limits each pulmonary lobule. Now, according to 
Dr. Sanderson, there are normally always, in the situation here indi- 
cated, masses of adenoid tissue, and the early stage of pulmonary tuber- 
culosis consists in a kind of hyperplasia of such masses. 

The connection then between tubercle and adenoid tissue may be 
freely admitted. Nevertheless it is quite certain that tubercle itself, 
like lymphadenoma, does not take its origin in adenoid tissue exclu- 
sively. The general result, deducible from recent observations with 
respect to the genesis of tubercular products, seems to be that, like the 
products of inflammation, they are not derived from any exclusive 
source; that they are probably not the results of specific hyperplasia of 
connective-tissue corpuscles alone, as Virchow teaches, nor yet simply 
overgrowth of the lymphatic corpuscles of adenoid tissue ; but that 
they are probably derived in variable proportion, from both of these 
sources, from the other cellular elements which happen to form part of 
the affected tissue, and even from immigrant leucocytes. 

The view here expressed has an important bearing on the question 
of " what is and what is not to be regarded as tubercle" — a question 
which is of the highest interest, in reference to the status of the morbid 
condition of the lung commonly known as pulmonary phthisis, and to 
the nature of the closely related, if not identical, morbid processes 
going on in other organs. According to the views generally accepted 
until within the last few years, the gray miliary tubercle and the 
yellow cheesy tubercle (which are both common in the lungs, and of 
w r hich the latter occasionally, by coalescence, infiltrates large tracts of 
tissue) were regarded as being not so much varieties as different stages 
of tubercular disease; and it was held that, in the dead-house, all the 
intermediate conditions, by which the minutest miliary tubercles lead 
up to the most extensive caseous infiltration, can be readily recognized. 
At the present day Virchow and many other distinguished patholo- 
gists deny this relation between miliary tuberculosis and the great 
majority of cases of caseous disease of the lungs; and maintain that 
these latter, which comprise probably all the cases recognized clinically 
as pulmonary phthisis, are of pneumonic origin, the consequences of 
catarrhal or lobular pneumonia. The grounds of this opinion are 
mainly, that in caseous infiltration of the lung, the presence of tuber- 
cular proliferation of the interstitial cell-elements is not a very obvious 
anatomical feature; and that the great bulk of the morbid mass consists 
of degenerate epithelial cells accumulated in the air-cells and smallest 
bronchial passages. Many important considerations, however, may be 
adduced in favor of the opposite view. It is a fully recognized fact 
that, even in clear examples of miliary tubercles, the proliferation of 
cells in the matrix of the pulmonary lobules, which constitutes their 
commencement, is soon attended with dense accumulation of cells 
within the pulmonary loculi, which cells are probably due to epithelial 
proliferation. Now, unless we start with the assumption that tuber- 
culosis consists in nothing else than proliferation of connective-tissue 



TUBERCLE. 



77 



corpuscles, or of the elements of adenoid tissue, what right have we to 
| assume that the protoplasmic bodies, which fill the air-cells, are specifi- 
j cally different from those which occupy the substance of the matrix? 
jl It is admitted that pus-cells may originate in epithelial as well as in 
' other kinds of cells; why should tubercle-cells have a more exclusive 
! parentage? It is a recognized characteristic of tubercle that its specific 
j cells very rapidly fall into degeneration ; but this characteristic is even 
i more remarkable in the cells which fill the loculi, than in those which 
j crowd the pulmonary matrix. Again, the caseous masses of pulmonary 
! phthisis certainly do not occupy those parts of the lung which either 
lobular or lobar pneumonia especially affects ; but they do occupy 
those situations (mainly the upper portions of the lungs) in which 
miliary tubercles generally originate, and are most advanced. And, 
lastly, caseous tubercles in the lungs are constantly associated with 
tubercular formations elsewhere in the body, and indeed in those very 
parts in which generalized miliary tubercles are specially apt to mani- 
fest themselves. For many reasons, therefore, of which we have only 
indicated the more important, we are disposed to maintain the relation- 
ship between miliary tubercles and caseous inflammation, to regard 
them simply as varieties or different stages of the same disease, and to 
support the claim of pulmonary phthisis or caseous pneumonia to be 
called also tubercular phthisis. 

The quasi-malignant character of tubercle is generally admitted ; 
although the mode in which it appears often to originate, almost 
simultaneously, in many points of one or more organs (in both lungs, 
for example), would seem to imply the existence, in some cases, of a 
tolerably Avidely-d iff used tendency of organs to become tubercular, 
independently of specific infection. The proof of its malignant attri- 
butes lies, partly in that tendency to general diffusion which it shares 
with growths which are unquestionably malignant, and partly in the 
facts, that its local spread is due chiefly to the establishment of new 
foci of disease in clusters around the primar}^ growths, and that the 
nearest lymphatic glands always become early secondarily affected. 
It was considered by Laennec (and his view in a very slightly modified 
form has been advocated by Dittrich and JSFiemeyer) that a caseous or 
softened degenerate mass of tubercle — a caseous lymphatic gland, for 
example — is a common, if not the invariable, source of generalized 
tuberculosis; that the degenerate particles taken up by the blood 
become distributed by it, and then act as specific irritants to the parts 
which they infect. 

The remarkable experiments first made by Villemin, and since 
repeated and extended by Wilson Fox, Sanderson, Cohnheim, and 
many others, in reference to the production of tubercle by inoculation, 
have a very interesting bearing on the points considered in the last 
paragraph. Guinea-pigs and rabbits were inoculated with tubercular 
matter; and it was found that, after the lapse of some weeks, small 
indurated caseous nodules had become developed at the seat of opera- 
tion, that the next lymphatic glands had undergone hyperplastic 
enlargement, and that the lungs, liver, serous membranes, and some 
other organs presented a greater or less number of small, gray, trans- 



78 



TUMORS. 



lucent, hard bodies which accurately resembled the miliary tubercles 
which occur in man ; and it was assumed that all these secondary 
formations were really tubercle, and consequently that tubercular 
detritus taken up by the absorbents, and then distributed throughout 
the organism, had a specific influence in the production of tubercle. 
It was soon proved, however, that the inoculation of other forms of 
growth, or of decomposing healthy tissue, or of the products of local 
inflammations excited by mere mechanical irritants, was quite as 
efficient in generating general tuberculosis, as was the inoculation of 
tubercular matter itself. And hence it became obvious, that the ex- 
citing cause of the tubercular development was not the matter which was 
inoculated or applied locally, but the product of the inflammatory 
process which the application of this matter evoked. The experiments 
therefore failed to prove the inoculability of tubercle, but they proved 
that tubercle might be produced locally by direct non-specific irritation, 
and that tubercle so engendered had the capacity for becoming general- 
ized. To a certain extent, then, these experiments may seem to favor 
the views of Laennec and Niemeyer as to the infective quality of caseous 
matter. It seems, however, more in accordance with what is now 
known of morbid proliferation, and of contagium, to assume that the 
infective element of tubercle is Hot effete and dead material, but rather 
living even though degenerating particles of protoplasm. 1 

The most common seats of tubercle are the lungs and the mucous 
membrane of the intestines. But tubercles are generally largely dis- 
tributed throughout the bodies of those who die tuberculous; and we 
may enumerate as their seats of election, after the lungs and bowels, 
the serous membranes, the spleen, the kidneys and liver, the brain and 
its membranes, the mucous surface of the genito-urinary organs, the 
suprarenal capsules and the bones, and of course the lymphatic glands. 

2. Syphilitic gummata have a close anatomical affinity with tuber- 
cle, on the one hand, and with inflammatory products on the other. 
They resemble granulation-tissue in the general character and arrange- 

1 Dr. Klein's investigations on the relation of the lymphatic system to tubercle, 
recently published in the Report of the Medical Officer of the Privy Council (New 
Series, No. 3, 1874), are exceedingly interesting. He shows that, in miliary tuber- 
cles of the human lung, " the first changes take place in the alveoli and inter- 
alveolar septa ; " that, as regards the alveoli, the epithelial cells become swollen and 
granular and detached, that they then proliferate, and that generally, either by their 
coalescence or by the disproportionate enlargement of one or more of them, each 
cavity becomes filled with a multinuclear lump of protoplasm or a so-called "giant " 
cell, which subsequently undergoes fibrillation, caseation, or other form of degener- 
ative change ; and that, as regards the interalveolar septa, these become more or 
less thickened, and consist of a tissue that contains branched and spindle-shaped 
cells and a few lymphoid cells. He adds, that, at a somewhat later period, cords of 
adenoid tissue are formed upon the walls of the larger vessels in the vicinity of the 
tubercles. He further points out, in reference to tuberculosis of artificial produc- 
tion, that although the ultimate changes are identical with those just described, 
they take place in an inverse order — the development of the perivascular adenoid 
cords preceding the changes in the interalveolar septa and in the air-cells. He 
concludes that, in artificial tuberculosis, the process commences from the arteries 
and veins, in the idiopathic affection from the pulmonary capillaries. This account 
of the formation of miliary tubercles differs somewhat from that given in the text, 
and is on the whole much more accordant than that is with the view, that gray and 
yellow tubercles are essentially identical. 



SARCOMA. 



79 



ment of their cellular structure, and in the facts that they are provided 
with permeable vessels, and that at an early period of their growth they 
are capable of conversion into cicatricial tissue. They tend, however, 
like tubercles, to undergo early caseation and death ; and, if their prog- 
ress be not modified by medical treatment, this may be regarded as 
their normal termination. It is in this latter condition, that they are 
almost invariably found post-mortem in the liver, testicles, brain, bones, 
and other internal organs. They then form opaque buff-colored tough- 
ish masses, imbedded in dense connective or cicatricial tissue. They 
are especially common in the skin and subcutaneous connective tissue, 
but here they generally undergo ulceration and leave indelible cica- 
trices. Excepting by their toughness, by the size which they attain, and 
by the paucity of their numbers, it would be exceedingly difficult to 
distinguish caseous gummata from tubercles in the same condition. In 
the brain and testicles especially, the resemblance between gummata 
and tubercles is remarkably close. 

Group 9. — Sarcomata. 

The term sarcoma was formerly applied to all tumors which were 
supposed to have a fleshy character, and hence came to be used very 
indiscriminately, and to have consequently no precise meaning. It is 
now, however, limited in its application to those growths which consist, 
not in their beginnings merely, but throughout the whole term of their 
existence, of embryonic tissue. Virchow regards them as belonging 
to the series of connective-tissue tumors, which have been already 
described, and shows that these latter, especially when they become 
generalized, tend to become more or less obviously sarcomatous — that 
is, tend to become more and more exclusively cellular, and to lose more 
and more their several distinctive characters. Sarcoma differs little, 
if at all, structurally from simple inflammatory granulation-tissue; 
both of them consist essentially of embryonic cells, which in the first 
instance are small, and round, and separated from one another by the 
least possible quantity of intercellular substance; in both cases there 
is a tendency for the cells, as organization proceeds, to become fusiform 
or spindle-shaped while still retaining their embryonic characters ; in 
both cases the anatomical and other features of the new-formed cells 
are modified, to some extent, according to the nature of the tissues in 
connection with which they arise ; and in both cases the growths become 
abundantly vascular from the development of new vessels, the parietes 
of which are formed of cells, little if at all modified from those which 
constitute the general mass. They differ however materially in the fact, 
that inflammatory formations tend to subside or to form mere cicatri- 
cial tissue, while sarcomatous tumors maintain a continuous vitality of 
growth, present a wider range of variations from the primitive type of 
structure, and are in large proportion malignant. 

Many varieties of sarcoma may be described. If sarcoma affects a 
bone, or an osseous tumor, or is attended in its progress with osseous 
transformation, we have what maybe termed an osteosarcoma ; and if, 
under analogous circumstances, Ave find sarcomatous growth associated 



80 



TUMORS. 



with simple fatty or mucous or gliomatous tissue, we have tumors 
which may be named respectively lipomatous sarcoma, myxosarcoma, 
and gliosarcoma. Again, sarcomata may undergo fatty or calcareous de- 
generation, or mucous softening, and thus acquire special characters. 
The occurrence of degeneration, and especially of mucous softening, 
often leads to the formation of cysts ; and thus arises that variety of 
sarcoma commonly known as cystosarcoma. 

Sarcomatous tumors are often, and perhaps best, classified according 
to the characters presented by the cells which predominate in them * 
the presence of any of the modifications, which have been above indi- 
cated, marking then only subordinate divisions of them, or varieties. 
There are at least four such species of sarcoma which we may enumerate 
and briefly consider : namely, (1) round-cell sarcoma, (2) spindle-cell 
sarcoma, (3) large-cell sarcoma, and (4) melanoid sarcoma. 

1. Round-cell Sarcoma. — In this species the structure of the growth 
approaches nearest to that of ordinary granulation-tissue, the cells being 
small, round, distinctly nucleated, and separated by little intercellular 
substance. Such tumors are nearly homogeneous, but soft and pulpy 
in texture, grayish or white in hue, opaque or slightly translucent, soft 
and pulpy, and yield (if they have been removed some hours from the 
body) a milky juice. They are very vascular, tend to attain enormous 
dimensions, and are malignant in a very high degree. They originate 
almost indifferently in all parts of the organism ; but especially per- 
haps in the skin and subcutaneous connective tissue, in glandular 
organs, more especially the breast and testicle, in bones and muscles. 
They comprise most of the tumors which have been called medullary 
sarcoma and encephaloid, and many of those which have been termed 
fungus nematodes. 

2. Spindle-cell Sarcoma. — In this case the growths consist of cells 
which have become elongated and fusiform, or spindle-shaped, of cells 
in fact which present a higher grade of development than those of the 
round-cell sarcoma. The cells vary a good deal in size, and contain 
each from one to two or three nuclei. They are arranged side by side in 
bands or groups, which take a curvilinear course and cross one another 
in various directions ; so that, on examining a microscopic section, we 
see round or oval groups of apparently round or oval cells, surrounded 
by bands of fusiform cells, the former being simply fusiform bands 
which have been cut across more or less obliquely. Spindle-cell sar- 
comata are harder and denser than round-cell sarcomata, grayish or 
white, slightly translucent, and of a more or less distinctly fibrous or 
lobulated character. They yield but little juice. They have a tendency 
to recur, and even to present malignant characters ; but their malig- 
nancy is far less pronounced than that of round-cell sarcomata, and 
they rarely reach the size which these latter attain. Spindle-cell sar- 
coma is synonymous with fasciculated sarcoma, and includes Paget's 
recurrent fibroid tumors. 

3. Large- cell Sarcoma. — In some cases the cells of sarcomatous tumors 
attain unusually large dimensions. The most characteristic example 
is that furnished by Paget's myeloid tumors of bone. These originate 
only in bones, destroy them extensively, and grow to a large size. 



CARCINOMA. 



81 



Tliev are made up to a considerable extent of embryonic cells, both of 
the round and spindle-shaped varieties; but that which distinguishes 
them from all other forms of sarcoma, is the presence of a greater or 
less abundance of large cells containing many nuclei. These cells, 
which are obviously derived from the many-nucleated cells which are 
found in the healthy medulla, vary greatly in most respects. They 
may measure as much as the hundredth part of an inch in diameter, 
and thus be objects distinguishable by the naked eye; they may be 
round 0£ oval, but generally are rendered irregular by the protrusion 
from them of a more or less complex arrangement of buds or tails; and 
they may contain any number of nuclei between two or three and two 
or three hundred. They consist of masses of protoplasm, unbounded 
by distinct cell-wall, and with the nuclei imbedded in their substance. 
Although myeloid tumors have unlimited powers of local growth, and 
even invade and grow along the veins, they are very rarely indeed 
malignant in the true sense of that word. 

4. Melanoid Sarcoma. — In this form of tumor the embryonic cells, 
which constitute it, are more or less loaded with minute pigment-gran- 
ules. The cells are round or oval or fusiform, generally the last, and 
separated by a small amount of intercellular substance; and each con- 
tains one or two distinct oval nuclei. The pigment-granules are round- 
ish or angular, and separately might pass for oily or cretaceous parti- 
cles ; they are deposited chiefly in the extra-nuclear protoplasm, and 
sometimes in such abundance that the cell under the microscope appears 
quite black, and the nucleus is altogether concealed ; but they are found 
also in the substance of the nucleus. Melanoid sarcomatous tumors 
are generally of soft consistence, and present if large a mottled sepia- 
brown or black appearance; if small, a more or less uniform black or 
brown hue. They take their origin almost invariably in structures 
which normally are pigmented, such as the choroid coat of the eye and 
congenital pigmented naevi ; and, if they become generalized, the sec- 
ondary growths repeat the pigmented character of the primary growth, 
thus furnishing a good example of the tendency, which secondary 
growths always have, to reproduce the specific characters of the parent- 
tumor. Melanoid sarcomata are generally highly malignant. 

Closely related to the sarcomata, and by Cornil and Ranvier placed 
among them, is that growth termed by Virchow Psammoma, which 
occurs solely in connection with the membranes of the brain and cord. 
It is vascular, soft, and friable, and chiefly characterized by an abun- 
dant development of concentric earthy concretions surrounded by cap- 
sules of flattened cells or scales. The type of these tumors is furnished 
by the choroid plexuses. They rarely attain a large size, and probably 
never cause mischief excepting they be large. 

Group 10. — Carcinomata. 

Carcinomatous tumors are considered, by Virchow, to be of a higher 
type than any of the tumors which have hitherto been considered; he 
regards them, not as the mere hyperplastic condition of a single struc- 
tural element, but as consisting of a combination of tissues, so arranged 

6 



82 



TUMORS. 



as to present some of the distinctive characters of an organ. And he 
includes them therefore in his class of organoid tumors. They are com- 
posed of a fibrous framework, or stroma, so arranged as to form a series 
of loculi, and of groups of cells which are contained in dense masses 
within them. The stroma consists for the most part of ordinary fibrous 
tissue and plasmatic cells, and carries and supports the arteries, veins, 
and capillaries, which are sometimes very abundant; it may be ex- 
tremely dense or comparatively lax, and varies much in quantity rela- 
tively to the size and number of the spaces which it invests. The loculi 
vary much in size, and on casual examination seem to be round or oval, 
and unconnected with one another; but as a rule they communicate 
freely, so as to form a series of branching channels. The cells are said 
by Virchow, and by many others, to be of an epithelial character; and 
they are so far epithelial, that they are developed from the surface of 
the loculi, and that they are in absolute contact with one another, have 
no intervening cement, and are never traversed as granulation-tissue is 
by vessels. They vary greatly in size, and on the average are consider- 
ably larger than those of sarcomatous growths. They vary even more 
remarkably in form, and indeed their polymorphous character is often 
regarded as typical of their carcinomatous nature. They may be round 
or oval, or from mutual pressure polyhedral; but more frequently they 
are of very irregular form, presenting convexities or concavities upon 
their surface, and projecting here and there into flattened, or pointed, 
or bulbous, or nondescript processes. They consist of masses of pro- 
toplasm, more or less granular and often fatty, containing within them 
one or more nuclei, which are for the most part round or oval, of com- 
paratively large size, and exceedingly well defined. Moreover they not 
unfrequently become vacuolated, or hollowed out here and there into 
globular cavities, which are termed by Virchow physaliphores, and are 
regarded by him as reproductive cavities. Carcinomatous cells have 
frequently a very close resemblance to the cells of the vesical epithelium. 
Cornil and Ranvier deny their truly epithelial character, mainly be- 
cause they have as a rule no distinct cell-wall, and because, although 
in contact with one another, they do not generally cohere. 

The origin of carcinomatous growths, like that of all tumors in fact, 
is very obscure. Rindfleisch, taking epithelial carcinoma as the type, 
considers that all carcinomatous tumors originate in the hyperplasia of 
epithelial structures, which as they grow eat their way, as it were, into I 
the subjacent tissues, hollowing them out into irregular cylindrical 
epithelial cavities, which then constitute the characteristic loculi of 
cancer. This mode of development calls to mind that of tubular gland- 
ular organs and hairs in the foetus. Cornil and Ranvier, on the other 
hand, who expressly exclude epithelioma from true cancers, and con- 
sider carcinomatous cells as being in no sense epithelial, conclude 
(mainly from their observations on the development of carcinoma in 
the bones and in the mammary gland) that the alveoli, within which 
the cells grow and multiply, begin in the plasmatic spaces or serous 
canaliculi, which are directly continuous with the lymphatic vessels, 
and that even when they attain their full size they maintain this con- 
nection ; so that in a sense the alveoli of cancer may be regarded as the I 



CARCINOMA. 83 

dilated origin of lymphatic vessels. To this connection, moreover, they 
attribute the peculiarly malignant character of all forms of carcinoma. 
Under any circumstances, however, the early stages of cancer are gen- 
erally marked by the formation of embryonic tissue, of cells therefore 
differing little from those which are found in inflammatory processes 
and in sarcomatous growths. But soon differentiation takes place, and 
the specific character of the growth is revealed by the conversion of 
some of these cells into the fibrous tissue of the stroma, and of others of 
them into the epithelium-like cells of theloculi. There is good reason, 
nevertheless, for considering that in many cases, and in some perhaps 
almost exclusively, the matrix consists of the normal fibrous elements 
of the part affected, which have simply undergone some degree of thick- 
ening and overgrowth; just as in other cases, when glandular organs 
are involved, their follicles and ducts may be stimulated to unwonted 
development, and so form prominent objects in the field of the micro- 
scope, without necessarily constituting any essential part of the specific 
growth. 

Like other adventitious growths, but in a greater degree than most 
of them, carcinoma is liable to undergo degenerative changes; these 
principally involve the cellular elements, and are sometimes so uniform 
in their occurrence as to give a special character to the case in which 
they prevail. Fatty degeneration of cells is the most common; but 
we meet also with caseous degeneration, calcareous deposit, and mucous 
softening; and not unfrequently extravasation of blood takes place, 
owing to the rupture of the morbid capillary vessels. 

All forms of carcinoma are malignant; the most malignant being 
the soft or encephaloid form of cancer, with its pigmentary and other 
varieties; the least malignant being epithelial cancer, which speedily 
involves the neighboring lymphatic glands, but very rarely indeed is 
reproduced in other parts of the system. 

The chief varieties of carcinoma are (1) Scirrhus or hard cancer; (2) 
Encephaloid or soft cancer; (3) Colloid or mucous cancer; (4) Epithe- 
lioma or epithelial cancer; and (5) Adenoid or tubular cancer. 

1. Scirrhus, in its typical form, is known especially by its hardness 
and slowness of growth. It creaks on section, and its cut surface pre- 
sents a white or grayish, glistening, fibrous character, and yields a 
little milky juice on being scraped. Its density and hardness are due 
to the great abundance and thickness of the fibrous matrix, and to the 
comparatively small size and numbers of the cell-containing loculi. 
The cells, however (which constitute the essential element of the milky 
juice), present the ordinary characters of cancer-cells. Scirrhous tumors 
rarely if ever undergo a complete cure ; yet it is certain, that they are 
not only of slow growth, but that their progress is specially apt to be 
attended with the degeneration (chiefly fatty or caseous) of the cells of 
considerable tracts, with the subsequent disintegration and removal of 
these cells, and the disappearance from such parts of everything except 
the fibrous stroma. Scirrhus is equally characterized by the slowness 
with which it involves obviously the neighboring lymphatic glands, 
and becomes generalized. It invariably, however, sooner or later 
manifests the infectious qualities which belong to it. 



84 



TUMORS. 



2. Encephaloid cancer is very soft in texture and rapid in growth, 
yields a very abundant milky juice, presents a tolerably uniform opaque 
white sectional surface, which, however, may be variously studded with 
patches of congestion or of hemorrhage, of fatty or of caseous degen- 
eration, or even of pigmentary deposition. Its extreme softness is due 
to the fact, that the fibrous stroma forms a very small proportion of 
the whole mass, while the cells are relatively very abundant. The 
alveoli vary in size, but are generally comparatively large, and their 
walls exceedingly delicate ; indeed, it is often difficult to recognize 
these latter at all, unless the cells be first removed by washing or 
pencilling. In encephaloid cancer, the secondary involvement of the 
nearest lymphatic glands, and of the general organism, takes place very 
speedily. 

Several well-marked varieties of encephaloid cancer are met with, 
two or three of which may be here enumerated. These are: 1st, erec- 
tile or hcematoid carcinoma, in which the vessels (always abundant in 
encephaloid) become extraordinarily developed and tend to frequent 
rupture; 2d, the variety, which Cornil and Ranvier term pultaceous 
carcinoma, in which the alveoli are thicker- walled than in most forms 
of encephaloid, but so large that they can easily be recognized by the 
naked eye, and from which the contents readily escape as a thick pulpy 
juice; 3d, lipomatous carcinoma, wherein the cancer-cells even from 
their infancy are loaded with oil, and in the adult state present so 
general and so large an amount of it that, both to the naked eye and 
under the microscope, the tumor has a considerable resemblance (at 
first sight) to ordinary fat; 4th, melanotic carcinoma, in which the cells 
contain, as in the corresponding form of sarcoma, pigment-granules in 
greater or less abundance. 

3. Colloid carcinoma has a very close resemblance to myxoma. In 
both cases the tumors are more or less transparent, and gelatinous in 
consistence, and in both yield from the cut surface an abundant juice, 
which is transparent, glairy, and characterized by containing mucin. 
The fundamental anatomical distinction between them, however, is 
this, that in myxoma the framework of the tumor consists of plasmatic 
cells, the mucous fluid and vessels occupying the interstices between 
them ; whereas in colloid carcinoma, the mucus arises in the mucous 
degeneration of the essential cells of the growth, the general solidity of 
the tumor being due to the presence of the fibrous stroma, which forms 
the walls of the alveoli. In colloid cancer the alveolar structure is 
extremely well-marked, and on this account colloid has often been 
termed alveolar cancer par excellence. The alveoli are so large as to 
be easily visible to the naked eye ; they are round or oval on section ; 
and when the growth forms a projecting mass on a serous surface, their 
aggregation presents the appearance of an accumulation of small bubbles 
of air in a viscid fluid. They communicate freely with one another. 
Their walls are mostly extremely thin and delicate, presenting a fibril- 
lated structure with an indistinct development of fusiform cells, which 
may themselves present appearances indicative of fatty or colloid degen- 
eration. The glairy contents of the alveoli vary, from the consistence 
of white of egg up to that of pretty firm glue, from pure white to a 



CARCINOMA. 



85 



more or less deep yellowish or brownish or reddish hue, and from per- 
fect transparency to tolerably complete opacity. Microscopically, can- 
cer-cells can always be recognized. In the smaller alveoli of the newly- 
developed parts, these may be discovered closely packed and completely 
filling them ; but even here many of them will probably be found to 
contain in their interior globules of mucus. As, however, the growth 
gets older and the alveoli larger, the cells undergo more and more 
complete mucous degeneration ; they swell up, acquire a comparatively 
enormous size, and presently disintegrate, leaving only a certain amount 
of granular detritus behind ; and thus in many cases the alveoli become 
distended with mucus, presenting a certain amount of granular matter, 
mostly arranged in irregularly concentric circles, with here and there 
perhaps the ghost of a huge dropsical cell. In addition to the mucous 
degeneration, which is the especial feature of colloid cancer, a certain 
amount of fatty degeneration is common. Calcareous deposition is also 
not unfrequent. 

Although colloid cancer is certainly malignant, and affects lymphatic 
glands, and occasionally becomes generalized, it is specially character- 
ized by a tendency, to spread over an extensive area, and to involve 
the tissues subjacent to that area. Thus, if arising in the peritoneum, 
it soon involves the greater part of that membrane, and soon also in- 
volves, in many situations, the whole thickness of the stomachal or 
intestinal walls. It shows also (though it is not peculiar in this respect) 
an obvious tendency to spread along the lines of the lymphatic canals 
and capillaries. 

4. Epithelioma or cancroid is a very characteristic form of growth, 
originating for the most part, but not quite exclusively, in epithelial 
tissue, and characterized by a very abundant formation of epithelium, 
in cavities or loculi of considerable size, which communicate, as in 
other forms of carcinoma, more or less freely with one another. 

The commonest form of epithelioma is that which originates in con- 
nection with the skin, and those portions of the mucous membrane 
which are most accessible from without, namely, that of the lips, tongue, 
and oesophagus, and that of the anus, vagina, and uterus. It forms a 
tumor which varies in size, very soon ulcerates, and on section presents 
(owing partly to the fact that the tissues which it invades are not yet 
wholly destroyed by it) a more or less variegated character; it is friable 
in texture, somewhat granular, and yields on pressure or on scraping, 
not a juice, but rather an opaque, whitish, granular pulp. The stroma 
of the growth consists of fibrous or of embryonic tissue, including 
vessels, and traces more or less abundant of the original healthy struc- 
tures. The pulp which exudes, and the contents of the loculi, consist 
solely of cells in different stages of development. These are distinctly 
nucleated, modified in shape by mutual pressure, and for the most part 
large and strikingly epithelial in character. The younger cells are in 
relation with the stroma, and occupy therefore while in situ the pe- 
riphery of each cell-mass ; the others are arranged in a more or less 
stratified or confused manner within. But we find in addition, in the 
latter situation, knots or nests or involucra of cells, the presence of 
which is almost conclusive as to the nature of the growth. These 



86 



TUMORS. 



consist of large flat stratified cells, arranged in concentric circles around 
a group of cells, or even a single cell of smaller size, of plumper form, 
thick-walled and containing a nucleus, and perhaps some mucous or 
colloid material, or a few small fat-globules. At first sight, these 
nests look not unlike transverse sections of cutaneous papillae, but they 
differ from these obviously in the fact that their centres are made up 
'of simple epithelial cells, and not of stroma containing vessels. 

As regards the development of epithelioma, there is little doubt that 
when it occurs in connection with epithelial surfaces, it commences with 
hyperplasia of the deeper-seated embryonic cells of the epithelium — 
in the skin, therefore, with hyperplasia of the cells of the rete mucosum 
and of the sebaceous and sudoriparous glands; in the mucous surfaces, 
with hyperplasia of the corresponding cells of their epithelium, and of 
those of the glandular crypts. These increase in number, and become 
modified in form and arrangement, distend the cavities or depressions 
in which they happen to be contained, and send thence into the imme- 
diately surrounding tissues bud-like processes. These latter increase 
in number and size, and thus gradually invade and destroy the neigh- 
boring textures. Rindfleisch quotes the observation, and reproduces a 
drawing of Koster, which seem to show that the extension of epithe- 
lioma is due to the involvement of the lymphatic networks; that the 
budding or sprouting epithelial processes above adverted to, instead of 
forming indiscriminately, penetrate the capillary lymphatics, run along 
them and distend them. There is probably some truth in this view, 
and, if so, it assimilates the local spread of epithelioma with that of 
colloid cancer, and especially with that of scirrhous and encephaloid 
cancer, as they are described by Cornil and Ranvier. 

Epithelial cancer is undoubtedly the least malignant of all the varie- 
ties of carcinoma, for it is the only cancer which admits of being re- 
moved in its early stage with the tolerable certainty that it will not 
recur ; and although it does very soon involve the neighboring lym- 
phatic glands, it very rarely indeed manifests itself secondarily in other 
internal organs. 

5. Adenoid or tubular cancer, otherwise termed columnar or cylin- 
drical epithelioma, is a rare affection, which is said generally to origin- 
ate on some mucous surface, and to involve secondarily lymphatic 
glands and other organs. It occasionally, ho vvever, arises primarily in 
the liver or other parenchymatous organs. It forms tumors of various 
sizes, which have a close general resemblance to those of encephaloid 
cancer. They are highly vascular, soft, and yield an abundant milky 
juice. Microscopically they are seen to consist of a system of tubules 
irregularly arranged, and separated only by a very small quantity of 
fibrous stroma, and bear a striking resemblance to sections of the cor- 
tical substance of the kidney deprived of Malpighian tufts. The 
tubules are for the most part cylindrical, of tolerably uniform size, and 
lined with a layer (usually single) of spheroidal or columnar epithe- 
lium. They present, for the most part, a distinct central cavity or 
canal. 1 This form of carcinoma is highly malignant. 



1 See Dr. Greenfield's account of a case of this disease in vol. xxv of the Path. 
Trans. 



CLOUDY SWELLING. 



87 



II. ATROPHY, DEGENERATION, AND NECROSIS. 

The term atrophy implies strictly a simple diminution in the bulk 
of tissues. The term degeneration, on the other hand, means degrada- 
tion of tissue, in other words, a qualitative rather than a quantitative 
change. A tissue which suffers atrophy simply wastes, while one 
which undergoes degeneration presents often an actual increase in 
bulk. Yet, although the terms atrophy and degeneration imply strictly 
different lines, so to speak, of decay, these conditions are so constantly 
associated that, in a practical sense, they scarcely admit of separation. 

When degeneration is in progress, we find that the elementary con- 
stitution of the parts involved becomes gradually confused and then 
destroyed, and that accompanying this process there is the appearance 
in them, for the most part in a granular or globular form, of fat or 
pigment, or other matters, which have normally no visible existence 
there. Whence do these matters come? Are they simply due to the 
decomposition of the highly organized material which has undergone 
degeneration, and to the precipitation from it of its more insoluble 
constituents; or do the decaying tissues attract them to themselves 
from the blood or extravascular nutrient fluid? There can be no 
doubt that both of these processes take place ; and that although they 
are distinct and not unfrequently dissociated, they generally concur; 
and that in most cases, where degenerative products are visible, they 
are due partly to simple precipitation, partly to infiltration. 

It will thus be understood that degeneration, in its widest sense, 
involves three processes which are essentially distinct from one another ; 
namely, first, simple atrophy or wasting of tissue; second, degenera- 
tion proper, or the decomposition of tissue; and, third, the deposition 
in the affected parts of insoluble matters derived from without ; and 
that these processes are generally associated, although in very various 
proportions. It should be added that the visible products of degenera- 
tion, according to the nature of which different names are given to the 
various degenerative processes, are only the more insoluble products of 
these processes ; that other effete or degraded matters are produced 
simultaneously, which are probably just as important, but which are 
difficult to recognize, partly on account of their solubility, partly be- 
cause they assume no crystalline, or molecular, or other visible form. 
We shall discuss the generally-recognized varieties of degeneration 
seriatim. 

1. Cloudy Swelling. — When cells are exposed to the direct influence 
of certain poisonous substances, or when they soak in the dropsical or 
inflammatory fluids which escape from the blood, they often become 
distended from imbibition, and at the same time their protoplasm 
assumes a very finely granular condition. The same changes, accord- 
ing to Cornil and Ranvier, take place in the nuclei and nucleoli. 
Virchow regarded them as the result of nutritive irritation. But they 
are generally admitted now to be of a degenerative nature, or at all 
events passive, and in many cases a first step towards fatty degenera- 
tion. The granules, however, are not fatty but albuminous, and readily 



88 



ATROPHY, DEGENERATION, AND NECROSIS. 



dissolved by acetic acid. This condition of cloudy swelling is well 
seen in the hepatic cells, in cases of acute atrophy of the liver. 

2. Mucous and Colloid Degeneration. — In many cases cells, and in 
some instances intercellular substances, undergo softening and conver- 
sion into matters which are known as mucus and colloid. These may 
form a thin glairy fluid, or present all degrees of viscidity between this 
and a thick jelly; and are transparent and colorless, or of different 
tints of yellow, brown, or red. They have therefore a very close re- 
semblance to one another; and indeed are not always easy to distinguish. 
They differ chemically in the fact that mucus contains mucin in solu- 
tion, a substance which is precipitated by acetic acid, while the specific 
element of colloid is an albuminous substance which is not affected by 
this reagent. 

Mucous degeneration sometimes involves the intercellular parts of 
tissues, sometimes the cellular elements. Of the former case, we have 
examples in the mucous softening which takes place in the matrix of 
the cartilages of elderly persons, and in that of enchondromata, and 
perhaps also in myxomatous tumors. The latter case is exemplified in 
the formation of globules of mucus within the cells of mucous mem- 
branes, and in the consequent distension of these cells and their final 
deliquescence. Mucous degeneration of cells is common at synovial 
and mucous surfaces ; it is a characteristic feature of the progress of 
colloid cancer ; and it is of not unfrequent occurrence in other forms 
of morbid growths, and then leads to the formation of cysts within 
them. 

Colloid matter is most frequently met with, in the cysts of the thyroid 
body, and in small renal cysts; and is generally, like mucus, formed 
first in the interior of the cells, which it presently fills and destroys. 
In the cases just referred to, it forms rounded jelly- or glue-like masses 
filling the cysts, and containing imbedded in them the remains of the 
cells which gave them origin. It seems probable that the glassy trans- 
formation described by Zenker as taking place in the voluntary muscles 
in typhoid fever, and which is marked by the presence in them of a 
peculiar waxy lustre, the disappearance of the normal markings, and a 
tendency to crack transversely, is really an example of colloid degen- 
eration. Further there is reason to believe that many so-called " fibrin- 
ous " casts of the urinary tubules are rather colloid matter than fibrin. 

3. Lardaceous degeneration, known also as waxy, bacony, albumi- 
noid, amyloid, and scrofulous degeneration, has (as the many names 
which have been applied to it testify) been long recognized, and pre- 
sents many very remarkable characteristics. It occurs al most exclusively 
in cases of tertiary syphilis, of chronic phthisis, and of long-continued 
suppuration, especially in connection with bone-disease; and indeed, 
since prolonged suppuration is constantly associated, both with the 
later stages of syphilis and with chronic phthisis, there is some reason 
to regard the lardaceous change as essentially the consequence of sup- 
puration. It affects mainly the liver, spleen, and kidneys; which in- 
crease slowly to many times their original bulk, become dense and 
homogeneous in texture, doughy in consistence, and present when cut 
a pale brownish tint, w T ith a slight degree of^ translucency and a peculiar 



FATTY DEGENERATION. 



89 



waxy lustre. Microscopically, the change is found to be due to the 
infiltration of the walls of capillary and other small vessels, of the 
walls of ducts, and of the substance of the cells, with a transparent, 
colorless, refractive material, which presents a jelly-like or vitreous 
aspect, which by its presence obliterates all their structural character- 
istics, and converts the vascular and duct walls into thick homogene- 
ous hollow cylinders, and the cells, with their nuclei, into refractive 
masses, with a tendency to irregular fracture. The microscopical 
appearances of parts which have undergone lardaceous infiltration are 
not altogether unlike those displayed by structures which are the seat 
of mucous or colloid change; but lardaceous matter is tougher and 
more consistent than mucous and colloid generally are; it invades 
structures which these latter never affect, and moreover never leads to 
the deliquescence and utter destruction of tissues. The chemical char- 
acteristics of lardaceous matter are of considerable interest. Yirchow, 
some years ago, finding, as he thought, that by the addition to it of 
sulphuric acid and iodine it assumed a blue color, concluded that it 
was identical with the cellulose of plants, which under the influence 
of the same reagents becomes first converted into starch and then blue, 
and hence gave it the name of amyloid matter — a name by which it is 
still largely known, although the theory which gave it origin is now 
only a matter of history. It has been indeed conclusively shown that 
lardaceous matter has no sort of chemical relation with starch or cellu- 
lose, and that the addition of sulphuric acid and iodine produces a 
bluish tint in consequence only of the precipitation of the iodine by the 
sulphuric acid in a molecular form. Lardaceous matter, in fact, is 
essentially a modification of albumen, with a deficiency of potash and 
of phosphoric acid, but with an excess of soda, hydrochloric acid, and 
especially of cholesterin ; and it is easily recognized by the fact that 1 
it rapidly absorbs iodine, even when this is applied in the form of a 
very weak solution, assuming a peculiar and very characteristic reddish- 
brown or mahogany tint. Dr. Dickinson has pointed out, as an equally 
characteristic test, the readiness with 'which it becomes stained blue by 
solution of sulphate of indigo. 

The presence of lardaceous degeneration does not, until it becomes 
extreme, necessarily impair the functional activity of organs. Its effects 
in this direction only show themselves late in the progress of the dis- 
ease, and are then probably due in great measure to pressure and 
other simple mechanical causes. 

Lardaceous degeneration, although occurring most frequently and 
most obviously in the organs which have been named, occurs also in 
other parts of the organism. Thus, it is not uncommon in the villi of 
the intestine and in the mesenteric glands ; and the so-called " corpora 
amylacea," which are common in the olfactory nerves and in the lining 
membrane of the lateral ventricles of the brain, not only present mi- 
croscopic characters resembling those of some forms of starch, but 
present the same chemical reactions as lardaceous matter occurring in 
other organs. 

4. Fatty Degeneration. — Three different conditions are not unfre- 
quently included within the meaning of this term : namely, overgrowth 



90 



ATROPHY, DEGENERATION, AND NECROSIS. 



of fat-tissue, superabundant storage of oil in cells (other than fat-cells) 
which normally are apt to contain a greater or lesser quantity of oil, 
and actual degeneration or decay of tissue attended with the appearance 
of molecules of oil in its substance. It is obvious that the first of these 
conditions is not a degeneration in any sense of the word. No doubt 
in many cases, as when it affects the heart, it does actually impair func- 
tional activity, but it impairs it by its mechanical influence only. The 
increased formation of fat is an example of hypertrophy or hyperplasia. 
Again, the second of the conditions enumerated above cannot properly 
be regarded as a degeneration. It is observed most characteristically 
in the liver, which, in phthisis and some other constitutional states, 
becomes much increased in size, paler and softer than natural, and 
greasy, and is found under the microscope to have its constituent cells 
distended with accumulated oil-drops. This condition of liver has 
long been known as fatty degeneration. But the liver-cells contain 
under normal circumstances a variable amount of fat. The presence, 
therefore, of fat in them is no sign that they are degenerate ; and more- 
over the accumulating fat does not lead to the destruction of the cells, 
nor does it (according to our experience) affect injuriously the perform- 
ance of the hepatic functions. The third of the above conditions is 
that which alone merits the name of fatty degeneration. 

Fatty degeneration commences almost invariably in cells or other 
forms of protoplasm, which become studded with minute refractive 
molecules, and at the same time increase in bulk. These molecules 
are supposed to be derived mainly, if not exclusively, from the degra- 
dation or decomposition of the protoplasmic matter itself, and are at 
first few in number and small in size, and collected chiefly immediately 
around the nucleus. Gradually they increase in number and become 
larger, conceal the nucleus and distend the cell; which latter then as- 
sumes a round or oval figure, and appears by transmitted light as an 
opaque black granular mass, constituting w T hat is generally known as 
a "granule-cell/ 7 and has been sometimes termed an " inflammatory 
corpuscle/' The last stage is represented by the further enlargement 
of the cell, its rarefaction and final deliquescence, with the setting free 
of the fat-granules which had been imbedded in it. In the later phases 
of fatty degeneration, when the cells are in great measure destroyed, 
and the oily matter is diffused throughout the tissues, cholesterin, 
which had doubtless been suspended in the oily molecules, separates 
from them, and appears amongst them in the characteristic form of in- 
complete rhomboidal plates ; and the whole tissue becomes confused, 
softened, reduced to an opaque yellowish-white pulp, and constitutes 
what is generally known as "detritus." 

The process above described is of common occurrence in nearly all 
vital tissues. Pus-globules, epithelial cells, connective-tissue corpus- 
cles, are all apt, in the course of inflammatory processes, to become 
granule-cells. Cartilage-cells undergo similar changes ; and the stel- 
late corpuscles of the cornea, and those of the inner coat of arteries in 
atheroma of that tunic, equally become the seat of dilatation and of 
fatty deposition. Fatty degeneration of muscular tissue is of much 
interest. It occurs as a normal process in the involution of the mus- 



PIGMENTARY DEGENERATION. 



91 



cular tissue of the uterus after parturition, and may often be detected 
in the hypertrophied muscular fibres of the walls of the stomach and 
intestines, when carcinoma or other such growths affect these organs. 
It is occasionally present in the voluntary muscles ; but is chiefly met 
with in the muscular fibres of the heart. Fatty degeneration of mus- 
cular fibre has indeed been principally studied in this latter organ. It 
commences with the appearance of fatty granules, in the corpuscles 
which stud the substance of the fibres, and in the immediate vicinity 
of their poles ; but presently the granules become more general in their 
distribution, the fibres lose their characteristic markings, and after 
awhile become, like granule-cells, mere accumulations of granular mat- 
ter. Fatty degeneration is often remarkably well exemplified in the 
cells of carcinoma, and of many other kinds of morbid growths. 

The term caseation is applied to that condition in which tubercles, 
syphilitic growths, carcinoma, and collections of pus, acquire the appear- 
ance and consistence of some forms of cheese. It is essentially fatty 
degeneration ; but it is fatty degeneration in which there is a deficiency 
of moisture, in which the degenerate cells therefore shrivel up instead 
of expanding and undergoing solution, and in which the diseased mass 
becomes dry and friable rather than pulpy or fluid. It was formerly 
supposed to be distinctive of tubercle. 

5. Pigmentary Degeneration. — The deposition of pigmentary matter 
is not, any more than that of oil, necessarily a pathological process ; 
nor, even when pathological, is it to be regarded as necessarily an evi- 
dence of degeneration. All pigment, originating within the body, 
appears to be derived from the hsematin or red-coloring matter of the 
blood, or from the coloring matter of the bile, which is itself a deriva- 
tive of hsematin. In either case, it may be simply diffused in a fluid 
condition among the tissues, or may be deposited in the form of gran- 
ules or small solid masses, or lastly, may assume a crystalline shape. 
And in either case again, it may present various modifications of color; 
of which red, yellow, brown, and black may be taken as the types. 
The various stages of pigmentation may be observed superficially in 
the progress of a subcutaneous bruise ; but to follow them thoroughly, 
it is necessary to investigate the changes which clots and the tissues in 
which they are imbedded present at different periods after extravasa- 
tion. The blood-corpuscles very soon lose their coloring matter, which 
speedily diffuses itself through the surrounding tissues, staining them, 
and more especially their protoplasmic particles, of a more or less 
bright yellow color. From this, ere long, granular pigment, of a 
yellow, brown, or black tint, is precipitated amongst the tissues, and 
in the clot itself ; and at the same time, probably, small refractive 
nodulated masses of a deep orange or pale red hue make their appear- 
ance. Lastly, small thick rhomboidal crystals, of a deep ruby color, 
are produced, which are generally termed " hsernatoidin " crystals. 
The final color which the granular form of pigment assumes is either 
brown or black; and this, together with hsematoidin crystals, which 
are unalterable, is the permanent indication of the previous existence 
of extravasated blood. A very nearly similar series of changes may 
be observed in connection with the liver, in cases where the excretion 



92 



ATROPHY, DEGENERATION, AND NECROSIS. 



of bile is prevented : namely, first, a general staining of the tissues, 
then a granular pigmentary deposit, and occasionally a more or less 
abundant formation of hsematoidin crystals scarcely if at all different 
from those which are obtained from blood. It should be added that, 
according to Stadeler, bilirubin differs from hsematoidin only in con- 
taining two more atoms of carbon ; and that the various modifications 
of color which bile undergoes by keeping are due to the development 
of substances which differ from bilirubin only in containing larger 
quantities of the elements of water, relatively to carbon and nitrogen. 

The pathological precipitation of brown or black pigment in a 
granular form is well seen: in the cells of the rete mucosum in Addi- 
son's disease, and in the brown discoloration which often succeeds 
various forms of skin disease and cutaneous inflammations — the result 
of chemical or other irritant applications ; in the cells of melanoid car- 
cinoma and sarcoma; and we might perhaps add, in the cells of the 
testis and of the gray matter of the brain, during the later periods of 
life. The deposition of yellow, red, and brown pigmentary granules 
and of hsematoidin crystals is, as before stated, a common result of the 
extravasation of blood. Accordingly these matters are found in cor- 
pora lutea, and in the neighborhood of apoplectic effusions, and in the 
parietes, in the interior, and in the vicinity of small vessels obstructed 
by clots or otherwise diseased. In certain cases of malarial fever, in 
which the spleen is seriously affected, black pigment masses are formed 
in that organ through decomposition of blood-corpuscles, are carried 
thence by the circulating blood, and deposited in the capillary vessels 
of other parts of the system. Black pigment, also derived from the 
blood, is frequently met with in the tissue of the lungs and in that of 
the bronchial glands. In reference to this latter case, however, we 
must not forget that carbonaceous matter, inhaled into the lungs, be- 
comes absorbed by the epithelial cells of the bronchial tubes ; and that 
hence, just in the same way as pigmentary matter, artificially intro- 
duced by tattooing, finds its way into the nearest lymphatic glands, so 
carbonaceous matter may be absorbed at the mucous surface of the 
bronchial tubes, and thence conveyed to the bronchial glands. Never- 
theless, the black pigment found in them is doubtless, in nearly all 
cases, chiefly of blood origin. 

6. Uratie Degeneration. — This occurs only in gout. It is charac- 
terized by the appearance, in the substance of articular cartilages, in 
the periosteum, synovial membranes, and tendons, of needle-like crys- 
tals of urate of soda. They are observed mainly in connection with the 
protoplasm of the cells, are often irregular in their arrangement, but 
very apt to form opaque densely arranged starlike clusters. 

7. Calcareous Degeneration. — This consists in the deposition of a 
combination of carbonate and phosphate of lime in some previously 
existing albuminoid matrix, with which it combines to form minute 
granules and spherules. These increase in size by concentric additions 
to their surface, and presently coalesce into botryoidal masses, the 
general form and arrangement of which are determined by the form 
and arrangement of the tissue in which the process is going on. The 
precipitation of calcareous matter takes place almost exclusively in the 



NECROSIS, OR GANGRENE. 



93 



intercellular substance; which first appears dusted with minute gran- 
ules, and then, as these multiply, becomes black and opaque to trans- 
mitted light. Later on, the enlarging granules run together, the 
blackness and opacity disappear, and the calcified tissue becomes 
refractive and transparent. Unless the cellular elements of the tissue 
which is undergoing calcareous transformation become destroyed, these 
remain, forming islets in its substance; and if they be stellate, and are 
at the same time numerous, the result is the formation of a mass 
having a very close resemblance to true bone. Calcareous granules 
have a superficial resemblance to globules of oil. They may be distin- 
guished, however, from them by their ready solubility (with the giving 
off of bubbles of carbonic acid gas) in hydrochloric and other acids, 
and if they be round by the appearance of a cross when examined by 
polarized light. Rindfleisch supposes that the pathological deposition 
of calcareous matter, which in the blood is rendered soluble by the 
presence of carbonic acid, takes place primarily at the periphery of 
cell-districts; and that it is due to the difficulty of reabsorption of 
nutrient matters which have found their way thither. This difficulty 
favors the separation of their more diffusible from their less diffusible 
constituents, and thus the removal of the dissolved carbonic acid, and 
the precipitation of the calcareous matters which the carbonic acid had 
rendered soluble. This explanation accords very well with Mr. 
Rainey's views on the formation of shells and bone. 

The deposition of calcareous matter is very common ; it occurs in the 
inner coat of arteries, and in the whole thickness of the walls of vessels 
of smaller size; it occurs also in tendon and cartilage, and even in the 
substance of skin. It is especially apt to take place in inflammatory 
and other adventitious products. Thus, we find plates of calcareous 
matter (often assuming the characters of bone) in old false membranes 
occupying the pleurae and pericardium, in the lining membranes of 
cysts, and in the choroid coat of the eye. And indeed, most degener- 
ative products, such as cheesy tubercles, inspissated pus and old clots, 
when they have lost their moisture, and most of their soluble or 
diffusible constituents, become the seat of calcareous deposition, and 
assuming first a mortary condition, finally shrink into calcareous 
lumps. But although earthy matter is deposited mainly in the tissues 
between cells, it is occasionally deposited in the interior of cells, and 
especially in those of unstriped muscle. By this means we find some 
of the smaller arteries converted into rigid cylinders, and large por- 
tions of muscular uterine tumors changed into calcareous masses. 

Necrosis, or Gangrene. — Several of the forms of degeneration, which 
have just been considered, end, as we have pointed out, in the disin- 
tegration and death of the tissues which they affect. We do not intend 
to pursue this question any further, or to speak of that form of death 
which results from the direct action of destructive agents ; but we 
propose to discuss very briefly the subject of necrosis, or mortification. 
This often occurs in the course of inflammation, and often affects 
rapidly-growing morbid growths ; but whether occurring in such cases 
as these, or in tissues or organs which seemed previously healthy, it is 



94 



ATROPHY, DEGENERATION, AND NECROSIS. 



always immediately due to obstruction of afferent vessels, or weakness 
of the heart's action, and the consequent more or less complete arrest 
of the supply of nourishment to the affected parts. 

When the death of some part of the organism takes place, the 
conservative influence of vitality ceases in it, its constituents fall under 
the unrestrained operation of chemical and other physical powers, and 
tend to undergo a series of destructive and often putrefactive changes, 
in virtue of which its complex organic constituents become gradually 
reduced to substances of much more simple elementary composition, 
and its various morphological elements lose in a greater or less degree 
their characteristic features. The rapidity, however, with which these 
processes take place depends necessarily upon the degree in which 
those conditions which favor them happen to be present. These are 
chiefly heat, moisture, exposure to oxygen or air, and to the various 
microscopic organisms which the air and water contain. Hence, it 
follows that gangrene is especially rapid, and its products especially 
fetid, when it occurs in superficial parts, or in the lungs, or in the 
course of the alimentary canal, where there is free exposure to oxygen 
in a more or less diluted form ; or when it occurs in parts which are 
juicy and loaded with blood, as they are if they have been the seat of 
inflammation, or if there has been previous obstruction of veins, or if 
(as sometimes happens) the arteries have still for a time been pumping 
into them a limited amount of blood — when in fact the gangrene is 
what is usually called " moist." When there is little moisture, and 
that moisture admits of ready removal by evaporation, or in other 
ways, and especially if there be at the same time entire protection from 
the influence of atmospheric air, the changes which ensue are very 
slow; the parts become inspissated, dried up, mummified; and even 
delicate structures retain for a great length of time their chemical and 
microscopical characters in a very slightly modified condition. A 
good example of this result is afforded by the changes which ensue in 
an extrauterine foetus long retained. 

Bone, teeth, hair, horny matter, elastic fibres, and cartilage resist 
putrefactive processes in a remarkable degree. But all the softer albu- 
minous or albuminoid tissues, and fat, change rapidly into a series of 
transitional compounds, the nature of which is not at all fully known. 
Some, however, are fixed, such as leucin, tyrosin, margarin, pigment, 
cholesterin, and triple phosphate; some are soluble but not volatile ; and 
others again are volatile and offensive, and give to gangrenous parts 
their characteristic fetor. Amongst these latter must be included sul- 
phuretted hydrogen, sulphide of ammonium, and valerianic and butyric 
acids. Ultimately, most albuminous and fatty matters become reduced 
in large proportion into carbonic acid, ammonia, and water. 

The visible changes which attend gangrene are not less remarkable 
than the chemical, but they correspond very closely with those which 
characterize ordinary degeneration. The blood becomes stagnant ; and 
very soon the coloring matter escapes from the red corpuscles and from 
the vessels, and infiltrates and colors all the tissues around. Thus, the 
course of the superficial veins becomes indicated by broad livid lines. 
Soon the diffused pigment becomes deposited in the form of brown and 



NECROSIS, OR GANGRENE. 



95 



black grains and even of haBmatoidin crystals, and its presence tends to 
give a characteristic hue to the parts. The red corpuscles themselves 
either melt away, or are converted into small angular pigmented bodies. 
The white corpuscles of the blood and other protoplasmic masses be- 
come somewhat opaque and granular, and then the seat of deposition 
of molecules of proteinous matter and of oil, and gradually assuming a 
caseous condition break up into fragments. The contents of fat-cells 
ooze through their membranous parietes, and diffuse themselves in 
globules of various sizes through all the tissues; and after awhile the 
solid fats crystallize out, and plates of cholesterin make their appear- 
ance. Muscular tissue, whether striped or unstriped, presents much 
the same changes as does protoplasm ; it first becomes somewhat opaque 
and then granular, and soon presents oil and pigment-granules in its 
substance ; presently it breaks up (the striped fibres tending often to 
split into transverse disks) and becomes a viscid confused mass. Double- 
contoured nerves early present obvious changes; the axis-cylinder 
undergoes the same transformations as other forms of protoplasm ; but 
the medullary sheath breaks up into globular, oval, and irregularly 
rounded refractive masses of an oily character, and presenting the pe- 
culiar features of w 7 hat is termed by Virchow " myelin.' 7 Ordinary 
connective tissue swells up, becomes opaque and granular, and then 
melts away. And bone, although it retains its characteristic form and 
appearance, loses its animal matrix. Many lowly organisms are apt to 
make their appearance in putrefying tissue, and by their presence and 
growth therein hasten the process of putrefaction. By far the most 
frequent and important of these are the minute omnipresent bodies 
which are known by the name of bacteria. 

We have adverted to the fact that the appearances and the progress 
of gangrene vary according to the degree in which the dead parts are 
exposed to the conditions which promote putrefaction. It must be 
added that the nature of the organ involved influences necessarily the 
nature of the result. Hence, we need not be surprised that gangrenous 
parts present great varieties of appearance. In internal organs, as the 
brain, the dead portion becomes soft and pulpy, its color opaque and 
yellowish, with perhaps a faint greenish tinge and a little red mottling, 
and the cellular constituents get granular and fatty, and presently re- 
duced to a mere detritus ; but no putrefaction ensues, no offensive prod- 
ucts are developed, and the more soluble and diffusible products are at 
once removed from the part by absorption. When an inflamed or con- 
gested leg or a strangulated portion of bowel becomes gangrenous, the 
affected part contains an extraordinarily large quantity of blood which 
escapes into the tissues, and assuming there the characters of black 
pigment, blackens them; putrefaction takes place very rapidly; a 
sanious fluid, charged with decomposing elements, and containing 
numerous globules of oil and much pigment, pervades the tissues and 
perhaps forms blebs at the surface ; and probably bubbles of offensive 
gas appear in similar situations. When gangrene occurs in the lung, 
the tissue often appears anaemic (sometimes, however, it is black with 
congestion), and presents in the first instance a translucent greenish 
tinge, but soon breaks down into a turbid greenish pulp of horrible 



96 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



fetor. In other cases again, as for example in sloughing ulcers, or when 
carcinomatous growths are sloughing, the parts which are actually dead 
assume a dirty opaque white appearance, and are thrown off in masses. 
Lastly, when the parts which die have been supplied with little blood, 
or lose the fluid which is in them rapidly by evaporation, the condition 
termed " dry gangrene" results. The affected parts then shrivel up, 
and gradually, by the retention of the blood-pigment within them, ac- 
quire a deep maroon or black color.; and, as was before pointed out, 
decomposition occurs very slowly in them, and they become dry and 
mummified. 

III. MECHANIC AL AND FUNCTIONAL DEBANGEMENTS. 

The various morbid processes of proliferation and degeneration 
which have been described, bring with them a host of mechanical and 
functional disturbances, which form essential elements of disease, and 
are often far more important, at all events far more striking, elements 
than are those other lesions which give rise to them. As regards func- 
tional disturbance, indeed, it is obvious that its presence implies the 
coexistence of some nutritive or other material lesion of the part or 
organ whose function is impaired ; and that its gravity must depend 
far less on the amount or quality of this material lesion than on the 
importance of the affected organ in relation to the well-being of our 
higher faculties, or to the maintenance of life. Thus, a fibromatous 
tumor, connected with the superficial parts, may attain enormous dimen- 
sions without materially influencing the general health ; whereas a 
very small growth of the same kind, involving the urethra or the in- 
testine, w r ould probably soon cause mechanical obstruction, and induce 
the usual symptoms of strictured urethra or bow T el. And thus, again, 
a tubercular mass or a hydatid may exist for some time imbedded in 
the substance of the brain, and yet give very little sign of its presence 
there ; whereas those functional disturbances of the central nervous 
organ which we know as acute mania and epilepsy depend on such 
slight lesions that even now they, in great measure, elude detection. 

a. Mechanical Derangements. 

These are not consequences solely of proliferation and degeneration. 
They do, however, very often indeed, arise out of them ; and for that and 
other reasons it seems convenient to consider them briefly here. They 
consist mainly of displacements of organs, of compression, contraction, 
and impaction, of dilatation, and of rupture and extravasation. 

1. Displacement of parts is exemplified in the altered position which 
the heart assumes when it is subjected to the pressure of unilateral em- 
pvema, or of a mediastinal tumor, and which this organ together with 
the lungs, acquires when there is extreme angular or lateral curvature 
of the dorsal spine ; it is exemplified also in the occurrence of hernia, 
intussusception, and prolapse of the rectum, and in the various flexions 
and other displacements of the uterus. 

2. Compression, contraction, and impaction. — The meaning of these 



MECHANICAL DERANGEMENTS. 



97 



words scarcely needs any explanation ; yet it may be well to illustrate 
their signification by reference to the modes in which tubular organs 
become affected by them. Compression of a tube means that it is re- 
duced in calibre, and perhaps modified in shape, by pressure acting 
upon it from without; contraction signifies that its bore is diminished 
by the inherent action of its own walls, or by morbid changes taking 
place in them — that there is in fact what is commonly called stricture; 
impaction implies that its channel is occupied by some foreign body or 
concretion. It is obvious that either of these conditions may end in 
the complete obstruction, or closure, of the tube. 

The effects of compression are manifested : when a large quantity of 
blood or of serum is effused upon the surface, or into the ventricles, 
of the brain ; when the lungs shrink under the pressure of accumulated 
serous fluid in the pleurae; when the heart becomes flattened, and inca- 
pable of dilating, under the influence of blood which has escaped into 
the pericardium from a ruptured aneurism ; when the trachea is pressed 
upon by a goitre or an aneurism ; when the intestines are strangulated 
by bands, or by the mouth of a hernial sac; when the rectum is ob- 
structed by the pressure of a diseased uterus. They are shown also in 
many cases in which organs are the seats of interstitial fibroid or other 
growths. Thus, in cirrhosis of the liver, we find that the newly-formed 
fibrous tissue contracts upon the essential elements of the organ amongst 
which it is distributed, and leads to their more or less complete destruc- 
tion. The same thing also happens, as regards the nervous centres, in 
the morbid condition now commonly termed "sclerosis." 

Contraction may be due either to some spasmodic action of the part 
affected, or to some growth (inflammatory or other) involving it. As 
examples of the first condition we have temporary contraction : of the 
cerebral vessels, causing epileptiform convulsions ; of the muscular walls 
of the bronchial tubes, causing asthma ; and of the sphincter ani and of 
the compressor urethras, producing respectively spasmodic stricture of 
the bowel and of the urethra. As examples of contraction due to in- 
flammatory or other changes we may enumerate : obstructive disease 
affecting the several cardiac orifices; laryngitis; malignant or other 
forms of growth involving the oesophagus, the pyloric or cardiac orifice 
of the stomach, the ileo-caecal valve, or the anus; and similar affections 
of any part of the genitourinary apparatus. It need scarcely be added 
that smaller and even microscopic tubes and ducts, such as those of the 
breast, of the kidney, and of the sebaceous glands, may become simi- 
larly obstructed. 

Impaction. — There are few tubular organs in which impediment from 
this cause does not occasionally take place. In the vascular system, 
especially in the systemic veins, thrombi or clots not unfrequently 
form, and cause obstruction. And in the same system, portions of such 
„ clots, or of inflammatory vegetations developed upon the cardiac valves, 
often become detached, and then carried onwards by the circulating fluid, 
until they reach some vessel which is too small to admit of their further 
progress, and where consequently they become fixed or impacted, and 
block it up. In the alimentary canal and the ducts which open upon 
its surface concretions frequently form, and, becoming fixed, cause more 

7 



98 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



or less serious consequences. Thus, the ducts of the salivary glands 
may be obstructed b) T the presence in them of salivary calculi, the 
common hepatic duct by the impaction of gallstones, and the intestine 
also by the impaction of gallstones of large size, or even by the pres- 
ence of indurated faeces. In the intestinal canal, moreover, indigestible 
substances, purposely or accidentally introduced, such as masses of hair, 
or of vegetable fibres, and so on, occasionally form concretions. Cal- 
culi are also of extremely common occurrence in the urinary cavities 
and passages. In considering this subject we must not forget to advert 
to the impaction, or (what is equivalent to impaction) the accumu- 
lation of abundant or tenacious secretions, by which cavities or canals 
are apt to become choked ; as occurs in cases of severe bronchitis, when 
the bronchial tubes become overloaded with muco-purulent secretion, 
and in inflammation of the kidneys, or in Bright's disease, when the 
renal tubules get blocked up by epithelial accumulations, or by blood 
or fibrinous casts. 

3. Dilatation of cavities depends, for the most part, on some dispro- 
portion between the pressure which their contents exercise upon their 
parietes, and the force which these parietes are capable of exerting in 
opposition to that pressure; and may thus be caused either by unwonted 
accumulation of contents, or by undue weakness of parietes, or by the 
concurrence of these two conditions. And, indeed, even when such 
dilatation does not originate in morbid weakness, however produced, of 
the walls of a cavity, it very soon causes it. But dilatation may occur 
in cavities of new formation, as well as in such as are of normal 
presence, and hence its discussion involves that of the growth, if not 
that of the origin, of cysts. 

Cysts are very commonly classified as a subdivision of tumors. A 
very little consideration, however, will suffice to show that cysts differ 
essentially from true tumors (that is to say, from neoplastic or prolif- 
erating growths), in the facts : that they are not themselves neoplasms ; 
and that when they occur, as they often do, in association with such 
growths, that association is a mere accident, depending either upon 
some structural peculiarity or some special tendency of the part 
affected, or of the neoplasm itself. Cysts may be divided generally, in 
accordance with their mode of formation, into at least four different 
groups, namely : a, those formed by dilatation of natural cavities • 6, 
those resulting from distension of ducts; c, those caused by extravasa- 
tion of blood; and d, those originating in the softening and destruc- 
tion of tissue, or in the dilatation of natural alveolar spaces. 

a. Cysts by Dilatation of Natural Cavities. — Among these must be 
included the pleurae, pericardium, peritoneum, tunica vaginalis, and 
synovial cavities, distended with dropsical or inflammatory exudation. 
They are exemplified also in the dilatations of the ventricles of the 
brain and cord, which constitute respectively the morbid conditions 
known as hydrocephalus and hydrorrhachis, and in the malformations 
of the same organs, termed encephalocele and spina bifida. Dilatations 
of the cavities of the heart, aneurismal dilatations of arteries and vari- 
cose conditions of veins, ovarian cysts, cysts of the broad ligament, 



CYSTS BY EXTRAVASATION. 



99 



those of the thyroid body, and many others, fall more or less obviously 
into this group. 

b. Cysts by Distension of Ducts or by Retention are even more common 
and more important than the last. We meet with them in the pul- 
monary system, when the bronchial tubes are dilated, and when 
emphysema is present. We meet with them in all parts of the alimen- 
tary canal ; in the oesophagus, when its walls are paralyzed, or when 
there is obstruction at the cardiac orifice ; in the stomach itself, under 
analogous conditions ; and in any part of the large or small intestines 
above the seat of an impediment, or when the parietes are weakened 
by inflammatory changes. When the hepatic, or pancreatic, or salivary 
ducts are obstructed by concretions, the tubes behind become greatly 
dilated. Cysts from this cause are exceedingly common throughout 
the whole of the genito-urinary apparatus. We find them here : when 
the bladder is distended, secondarily to the presence of a urethral stric- 
ture; when, under similar circumstances, the ureters and the cavities 
of the kidneys become dilated ; and when, owing to their obstruction, 
the tubules of the kidneys expand into renal cysts. They occur also 
in the uterus or Fallopian tubes, or the tubules of the testes, when 
these dilate in consequence of some stricture or other impediment to 
the escape of their contents; and under similar circumstances, in the 
breast, and in the sebaceous, and almost all other glands. 

A variety of this mode of formation of cysts has been described by 
Dr. Wilson Fox and others, in certain cases of multilocular cysts of 
the ovary. They state: that papillary growths take place from the 
inner surface of a comparatively large cyst ; that these, as they increase 
in length and bulk, become closely packed against one another, and 
finally coalesce in numerous points, leaving irregular chinks between 
them ; which chinks then, by the retention of the secretions of their 
parietes, become gradually dilated and ultimately converted into dis- 
tinct cavities. 

c. Cysts by Extravasation. — Blood effused either into cavities, or into 
the substance of organs, undergoes a series of degenerative changes. 
In some instances these result in the softening and breaking down of 
the central portion of the clot, and in the consequent formation of a 
cyst. The best examples of cysts thus formed are furnished by the 
brain and the cavities of the heart — in the former case, as a consequence 
of the changes which take place in apoplectic clots ; in the latter, as a 
consequence of the softening of clots which have formed some time 
anterior to death. Clots imbedded in the substance of the brain 
almost always undergo absorption, and leave behind them cysts filled 
with clear fluid, traversed by delicate filamentous bands, and bounded 
by tissue still colored with blood-pigment ; those occupying the cavi- 
ties of the heart break down into an opaque milky fluid, charged with 
degenerate blood-elements. It not unfrequently happens that cysts 
are formed in the interior of sarcomatous and other soft and highly 
vascular tumors, by exactly the same process as that which produces 
apoplectic cysts. It may be added that extravasated blood, especially 
if it be extravasated in successive strata, in many cases forms solid 



100 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



masses, which may then become organ ized, and constitute, according 
to their position, the various forms of "blood-tumor" or hcematoma. 

d. Cysts by Softening of Tissues. — These are generally due to the 
occurrence of one or other of the degenerative processes, which have 
been described. We meet with them in abscesses, and in cases where 
the tissues have undergone either mucous, colloid, or fatty softening. 
Hence, putting abscesses on one side, they occur most frequently in 
proliferating growths ; and indeed, in some cases of disseminated 
tumors the majority of them become thus hollowed into cavities. 
Bursa? in unwonted situations must be included in this group. 

It may be worth while to point out : that, as cysts dilate under the 
influence of their accumulating contents, their parietes, which very often 
increase at the same time in thickness, tend to become lacerated or to 
yield at points ; that thus, pits which gradually increase in area and in 
depth are formed in them ; and that these not unfrequently end in 
perforation or rupture, and, in the case of cysts separated by a party- 
wall, in the establishment of communications between them. We may 
also mention that the inner surfaces of cysts, contained within the sub- 
stance of proliferating growths, may, however the cysts have been pro- 
duced, become lined with epithelium, and the seat of new outgrowths; 
and that hence we not unfrequently see springing from the inner sur- 
face of such cysts, fungous, papular, villous, or cystic formations, just 
as they may spring from the diseased mucous, serous, or cutaneous 
surface. 

4. Rupture and Extravasation. — The occurrence of rupture and ex- 
travasation, to which the distension of cavities and of canals ultimately 
tends, is an event of great pathological importance, and often of the 
gravest danger. Such accidents are common. Sometimes the heart 
becomes torn, and the pericardium consequently distended with extrav- 
asated blood. The rupture of aneurisms and of varicose veins is, we 
need scarcely say, of extreme frequency. In the lungs, the progress of 
vesicular emphysema is largely dependent on rupture of air-cells ; and 
in interlobular emphysema, and in pneumothorax, we not only have 
laceration of tissue but extravasation of air. Laceration of the stomach, 
in ulcer of that organ, or of the intestine in the course of typhoid fever, 
is attended with the escape of its contents into the peritoneal cavity. 
Again, abscesses and hydatid cysts often become ruptured, and dis- 
charge their contents; and, indeed (as we have above pointed out), 
cysts of all kinds are liable, in various degrees, and with various re- 
sults, to similar accidents. 

b. Functional Derangements. 

To discuss these thoroughly would involve an analysis of nearly all 
the symptoms of all diseases. Morbid processes, indeed, are recognized 
mainly during life by the functional disturbances to which they give 
rise ; and some diseases are — so far at least as we know them — nothing 
more than groups of such disturbances. Each organ of the body, every 
particle of the organism, has its appropriate duties to discharge; and, 



CONGESTION. 



101 



under the influence of morbid processes, these duties become increased 
or diminished, and in either case probably more or less profoundly 
modified. The function of the eye is to see, that of the muscle to con- 
tract, that of the kidney to excrete urine ; but the eye may be unduly 
sensitive to light, or its power of distinguishing objects may be im- 
paired, or it may see things which have no real existence; the muscle 
may contract with spasmodic violence, or it may be thrown into clonic 
convulsive action, or it may lose its power of contraction altogether; 
the kidney may cease to excrete urine, or it may separate from the 
blood a portion only of the usual urinary constituents, or matters 
which are altogether foreign to the normal constitution of that fluid. In 
these and in many other ways the organs which have been named may 
present signs of functional disturbance ; and it need scarcely be said 
that similar observations may be made in reference to every other 
organ. We do not propose, however, to enter here upon the consideration 
of functional derangements generally, for most of them will be best 
discussed when we come to speak of local diseases. But some, which 
are connected more especially with the vascular and nervous systems, 
enter so largely into the complex phenomena of disease, form such im- 
portant elements of diseases which are fundamentally distinct from one 
another, that it will be convenient to give them separate and imme- 
diate consideration. We refer especially to congestion, dropsy, fever, 
the typhoid condition, collapse, and death. 

1 . Congestion. 

Accumulation of blood in the vessels of a part is necessarily asso- 
ciated with dilatation of the vessels which are implicated; but, as we 
have pointed out in speaking of inflammation, this dilatation may be 
active, and the accumulation of blood therefore secondary to it, or it 
may be passive, the vascular walls yielding under the pressure of the 
blood internal to them. 

Active congestion is due to active dilatation of vessels, that is, to 
dilatation originating in an inherent power of dilating, which the mus- 
cular fibres and other protoplasm of their walls have now been shown 
conclusively to possess. This dilatation commences for the most part 
in the small arteries, and presently involves the capillaries and small 
veins. Active congestion is constantly connected with inflammation, 
at least in its earlier stages, and generally with morbid proliferation. 
And as, in health, we recognize its temporary presence in the cheek 
which blushes with shame, and in the general surface after violent ex- 
ercise ; so, in disease, we recognize its temporary presence in the hectic 
flush of phthisis, and in the general redness which attends many 
forms of febrile disturbance. 

Passive congestion has been divided, unnecessarily, it seems to us, 
into two varieties, namely : first, that which is dependent solely on loss 
of power in the walls of the dilated vessels; and, second, that in which 
the dilatation is traceable to some mechanical impediment to the pas- 
sage of blood through the veins. There is doubtless a theoretical dis- 
tinction between them ; yet it is obvious that the dilatation is really in 



102 MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



both cases passive, and due to the fact that the vessels yield under the 
internal pressure to which they are subjected. The first case is exem- 
plified, — by that dilatation of vessels which attends the later stages of 
inflammation; and by that permanent enlargement of vessels which is 
often seen in the vicinity of old ulcers, and of inflammatory and other 
formations, and is so common in the noses and cheeks of persons who 
have been given to drink, or have been exposed to the influence of 
weather, or who suffer from acne rosacea. The second variety is ob- 
served in cases of obstructive heart disease, and under analogous cir- 
cumstances in circumscribed portions of the vascular system. In dis- 
ease of the mitral valve, in emphysema, and some other affections of the 
lungs, and especially in disease of the valves on the right side of the 
heart, the blood becomes delayed in the systemic veins, and these gen- 
erally dilated — the dilatation affecting successively the trunk-veins, 
their tributary branches, and the capillary veins. We often indeed see 
in such cases: groups of minute veins forming varicose subcutaneous 
tufts : and still more frequently, persistent livid congestion of the nose 
and cheeks, of the hands and fingers, and of the feet and toes, due to 
general overdistension of their capillary veins and capillaries. Similar 
passive congestions affect the internal organs; especially the liver, pro- 
ducing the " nutmeg" condition of that organ ; and the kidneys, causing 
induration and the secretion of albuminous urine. We will adduce 
a few other examples in which local obstructive diseases cause local 
congestions. Whenever a vein becomes obstructed by a thrombus, or by 
external pressure, the tributary veins undergo precisely those changes 
which the veins generally undergo in heart disease. Thus, if there 
be an aneurism, or other tumor, in the upper part of the chest, and the 
descending cava or one of its branches is compressed by it, the veins of 
the head and neck and upper extremities, or those of one side, become 
distended and overloaded ; if the femoral vein be blocked up by a clot, 
the veins of the foot and leg get similarly affected ; if the lateral sinus 
be thus obstructed, enlargement and congestion of the retinal veins, 
and of those of the conjunctivae and eyelids, not nnfrequently occur. 
Again when, owing to cirrhosis or other hepatic disease, the passage of 
blood through the portal vessels is impeded, the veins of the mucous 
membrane of the stomach and bowels tend to become overdistended, 
and occasionally relieve themselves by actual haemorrhage. We may 
acid that the mere statical pressure of a column of blood, which we 
know is competent to produce a varicose condition of the veins of the 
lower extremities, is competent also to produce dilatation of the smaller 
veins and capillaries. Nor should we omit to point out, that mere 
feebleness of the heart's action, in other words, insufficiency of force to 
propel the blood onwards, such as occurs in the later periods of heart 
disease, leads to the stagnation of blood in the capillary and other 
small vessels, and hence to passive congestion ; and that obstruction of 
an artery, on almost the same principle, very often, as we see in the 
lungs and kidneys, allows the territory to which the artery is distrib- 
uted to become the seat of intense congestion and even of haemorrhage. 



DROPSY. 



103 



2. Dropsy. 

Dropsy is the accumulation of serous fluid within the cavities of the 
body, or in the areolar spaces of the connective tissue. It depends 
either, like passive congestion, upon mechanical obstruction to the flow 
of blood along the veins, or upon the presence of inflammatory or other 
analogous processes, or upon some morbid condition of the blood or 
bloodvessels, or, lastly, upon obstructive disease of the lymphatic tubes 
or glands. Further, dropsy may be local or general, and dependent 
therefore on local circumstances or on causes which act universally. 

The causes of general dropsy, or anasarca, are for the most part ob- 
structive diseases of the heart, morbid conditions of the lungs impeding 
the circulation through the pulmonary vessels, affections involving the 
secreting structure of the kidneys, and certain morbid states of the 
blood or tissues. The general dropsy which attends heart or lung dis- 
ease is, like the congestion which also attends these affections, purely 
mechanical, and indeed may be regarded as the sequel of that conges- 
tion. In the healthy condition the thin walls of the capillary vessels 
and small veins allow a constant escape of the serum of the blood into 
the tissues which are external to them — the quantity, which thus escapes 
in a given time, being largely dependent on the varying degrees of 
pressure within the vessels, and on the more or less facility with which 
the lymphatic vessels perform their proper absorbent functions. Now 
when a mechanical obstacle exists to the transit of blood through the 
heart or lungs, the systemic veins and capillaries soon become over- 
loaded, and the pressure upon their inner surface rapidly rises. And 
we can readily see therefore that, while there arises, on the one hand, 
a greatly increased tendency for the serum of the blood to transude at 
the peripheral distribution of the venous system ; there is developed, 
on the other hand, a tendency at the opposite end of that system to 
impede the entrance of the contents of the thoracic duct ; and that 
hence the fluid, which is effused into the tissues in abnormal quantity, 
is absorbed with difficulty, and dropsical accumulation necessarily en- 
sues. Cardiac and pulmonary dropsies are, as their mechanism would 
indicate, always associated with more or less obvious congestion, and 
almost invariably first show themselves in the parts which are most de- 
pendent. The explanation of renal dropsy is not so clear. It obvi- 
ously does not depend on any obstacle to the circulation existing in the 
heart or lungs, or on overdistension of the venous system with blood, 
or, we may add, on any similar distension of the capillary vessels; for 
the patient usually presents a very anaemic appearance, even when the 
blood itself is not abnormally pale. There is, however, in renal dis- 
ease very unmistakable obstruction throughout the whole capillary ar- 
terial system ; for as Dr. George Johnson has well shown, the small 
arteries generally become extremely thickened and their canals propor- 
tionately contracted ; and we know that the left ventricle of the heart 
becomes hypertrophied to overcome some impediment — doubtless the 
mechanical impediment which Dr. Johnson has discovered existing at 
the periphery of the vascular system ; and that, associated with these 



104 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



conditions, there is, as we should expect, greatly increased blood-pres- 
sure in the arteries. It seems hardly likely, therefore, that the escape 
of fluid into the tissues should in this case take place through the capil- 
laries and capillary veins ; but, on the other hand, it seems very proba- 
ble indeed that it takes place through the thickened capillary arteries, 
in consequence of the extreme internal pressure of fluid to which they 
are subjected. It can scarcely be objected to this explanation that the 
thickened condition of the walls of the small arteries would counteract 
the tendency for fluids to transude through them, in face of the fact 
that the hyaline thickening of the walls of the Malpighian vessels of 
the kidney, in lardaceous disease of that organ, is not incompatible with 
a profuse discharge of urine. In pure renal anasarca the skin is usually 
remarkably anaemic and waxy-looking, and the dropsy is often first 
detected, not in the lower extremities, but in the eyelids and the scro- 
tum. General dropsy occasionally takes place in persons who, from 
whatever cause, are in a state of anaemia; it is especially common in 
chlorotic girls. We know that in these cases the blood is in a state of 
unnatural dilution ; that the muscular tissue generally, including that 
of the heart and probably that of the bloodvessels, is enfeebled ; and 
that the circulation, therefore, even though the heart acts quickly, is 
languid ; and we are hence justified in assuming that the anasarca is due 
either to the fluidity of the blood, or to the languor of the circulation, 
or to a combination of these conditions. It need scarcely be remarked 
that the supervention of anaemia, in the course of disease of the heart 
or kidneys, is very often the determining cause of an attack of ana- 
sarca which otherwise would have been escaped ; and that anaemia is, in 
many respects, a very serious complication of the diseases of these and 
other organs. 

Local dropsy depends either on mechanical obstruction of the prin- 
cipal vein or veins leading from the dropsical 'part, or on obstruction of 
the lymphatics, or on the presence of inflammatory or other like pro- 
cesses. When it depends on venous obstruction, we have, within a cir- 
cumscribed space, very nearly the same conditions as those which, in 
cardiac disease, affect the whole body; a vein becomes impervious, its 
tributary branches down to the capillaries become distended with blood ; 
the serum of which presently escapes into the tissues in larger quanti- 
ties than the lymphatics are able to remove. The most important va- 
riety of local dropsy from venous impediment is that which takes place 
in the abdomen, when the passage of blood through the portal vein is 
impeded by cirrhosis, or by growths occupying the transverse fissure 
of the liver. But any vein may be obstructed, either by pressure from 
without or by a coagulum within it; by obstruction of the superior 
cava (as we see sometimes in cases of thoracic aneurism) enormous ana- 
sarca, limited to the head and neck and arms, may be produced ; from 
obstruction of the inferior cava (even from so slight an amount of it as 
results from the pressure of ascitic fluid), dropsy limited to the lower 
extremities may arise; and in consequence of obliteration of the bra- 
chial or femoral vein anasarca of the corresponding arm or leg may 
ensue. It has been already pointed out that, whenever inflammation 
is in progress, a considerable excess of the serum of the blood is poured 



FEVER. 



105 



out into the tissues; and that, especially when the parts involved are lax 
or present some suitable structural peculiarity, the effused serum accu- 
mulates in them, producing a more or less obvious dropsical condition. 
We see this in the oedema of the eyelids, which attends the formation 
of a common stye; in the dropsical condition of the tissues around 
the joints, in rheumatism and gout; in the cedematous state of the leg, 
when erythema nodosum or slight periosteal inflammation is present; 
but Ave see it especially in inflammation of the serous and synovial 
membranes. Inflammation of the pleura constantly causes hydrotho- 
rax, inflammation of the pericardium hydropericardium, inflammation 
of the peritoneum inflammatory ascites, and inflammation of the syno- 
vial membrane hydrops articuli. The effusion of serum in excess also 
attends the development of tubercle, carcinoma, and other forms of ma- 
lignant growths ; and we consequently often find the serous cavities 
full of dropsical fluid, in connection with the growth of such tumors 
from their parietes. It may, perhaps, in some of these cases, be a 
question as to how far the dropsy which is present is due to the mere 
excess of effusion naturally attending morbid proliferation, how far it 
may be attributed to obliteration of some of the veins leading from the 
great omentum and other parts. The remaining form of dropsy to 
which we have adverted is that which is due to lymphatic obstruction. 
We have already briefly considered this subject in connection both with 
fibroma and lymphoma ; and need say no more about it now, than that 
occasionally the lymphatics of a limb or organ become obstructed, and 
that then (to take the case of the limb) the whole member becomes 
tense, elastic, pale, and infiltrated with fluid having the chemical and 
microscopical characters of lymph; that the tissues thus soaked in nu- 
trient fluid tend to become hypertrophied ; and that here and there 
subcutaneous vesicles, which may be regarded simply as dilated lym- 
phatic passages, make their appearance, and from time to time rupture, 
and discharge large quantities of lymph. 

In cases of general dropsy, whether of cardiac or of renal origin, 
both the general connective tissue and the various serous cavities, be- 
come as a rule involved in pretty nearly equal proportion; but now 
and then, in association with slight anasarca, there may be extreme 
ascites, or extreme effusion into one of the pleurae. In such cases the 
local excess of effusion is necessarily due to the co-operation of some 
local cause — the ascites, for example, to a nutmeg condition of the liver, 
or to some slight peritoneal inflammation; the pleuritic accumulation 
either to slight general pleuritis, or to the circumscribed inflammation 
of the pleura which is usually excited in the neighborhood of pulmo- 
nary apoplectic clots. 

Fever. 

By the term "fever" is meant that abstract condition which is com- 
mon to all so-called " febrile disorders," and the presence of which 
gives them their claim to that designation. Essentially it means undue 
elevation of temperature; the immediate or proximate causes of that 
elevation ; and the consequences which these conditions entail. 



106 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



The normal temperature of the body has been variously estimated ; 
but on the average seems in the adult to range between 98.4° and 
99.5° ; in the infant to stand at a somewhat higher figure. It presents, 
however, within narrow limits, numerous variations. First. The most 
constant and important of these is the diurnal variation, which rarely 
exceeds 1.5°, but occasionally amounts to as much as 3.5°. The mini- 
mum temperature, according to Dr. Jiirgensen, occurs from 1.30 a.m. 
to 7.30 A.M.; the maximum from 4 p.m. to 9 p.m. — the temperature 
between 7.30 A.M. and 4 p.m. rising with some fluctuation ; that 
between 9 p.m. and 1.30 a.m. gradually falling. This daily variation 
corresponds pretty accurately with similar variations in the activity of 
respiration and circulation. Second. A slight but decided elevation 
of temperature usually follows the ingestion of food. Third. Muscular 
exercise has a similar influence; although, as Dr. Davy has shown, 
this elevation manifests itself less by actual increase of the temperature 
of the internal organs, than by the general diffusion of that tempera- 
ture throughout the organism. Fourth. The external temperature, 
again, influences that of the body in a greater or less degree. But, 
under ordinary circumstances, its influence is much less than might be 
supposed ; for variations of season in our own climate have a scarcely 
perceptible effect, and even tropical heat and arctic cold rarely disturb 
the temperature of the internal organs beyond a degree or two. The 
influence of external temperature, however, depends upon the condi- 
tions under which it is exerted ; for, if these be favorable, the general 
heat of the body may be very largely and rapidly augmented or 
lowered, and to a degree even which is incompatible with the main- 
tenance of life. Thus, whenever the medium (air or water), in which 
the body is immersed, is in rapid movement, it will, if of a higher or 
lower temperature than the body, elevate or depress its temperature 
in a much greater degree than if it w T ere at rest ; and again, whenever 
perspiration is impeded, as it necessarily is in a moist atmosphere, or 
in water, the effects of heat are exerted with special efficacy. 

The conditions which determine the heat of the body, and which 
regulate it, have been investigated with considerable success. It is 
certain that, in accordance with the laws of force, no heat can be devel- 
oped in the body, save such as may be traced, directly or indirectly, 
to the latent heat of the substances which are ingested as food ; that the 
total amount of heat which the body is capable of evolving is simply 
that which would be emitted in the course of its entire destruction by 
burning ; and that, neither in its parts nor as a whole, has it any more 
power of creating heat than of creating matter. It is obvious, there- 
fore, that the development of heat within the body is simply due to 
the setting free of latent heat by the destructive oxidation which is 
constantly going on in it; and that the amount of heat developed in 
any given time is an exact measure of the amount of oxidation which 
has taken place in that time. It is equally obvious, that the excreta 
furnished by the skin, lungs, kidneys, and alimentary canal (repre- 
senting as they do the lowest degree of degradation to which the 
alimentary matters have, after various changes, become reduced), must 
furnish the means of determining exactly both the amount of oxidation i 



FEVER. 



107 



which has been effected, and the amount of heat which has been 
evolved. Ranke, by comparing the daily quantity and quality of the 
food with the daily quantity and quality of the excreta, has arrived 
at the conclusion that the healthy adult body evolves on the average 
enough heat in twenty-four hours to raise 44 lbs. of water from the 
freezing- to the boiling-point; and it has been estimated further, that 
of this heat 2.6 per cent, goes to the elevation of the temperature of the 
food ingested; 5.2 per cent, to the warming of the air breathed; 14.7 
to the vaporization of the water discharged by the lungs ; and 77.5 to 
the radiation and evaporation from the skin. 

The above statements, however, only represent the final result which 
is attained, after many transmutations within the body during which 
heat becomes alternately latent and sensible. We know, for example, 
that heat is essential for the maintenance of the corporeal functions, as 
it is for that of the functions of the steam-engine ; that every act of 
growth and development, every nervous operation, every muscular 
contraction, is dependent on the heat developed by oxidation, and 
attended with the temporary disappearance or absorption of a certain 
quantity of heat; while, on the other hand, everything which inter- 
feres with or impedes or arrests the performance of these functions — 
the friction of the blood against the capillary and other vessels, of the 
muscular fibres against one another, every opposed muscular effort, and 
possibly even the constant passage of nervous currents along the nerves 
— is attended with the reappearance of that heat in a sensible form. 

It remains to consider on what conditions the regulation of the 
amount of heat developed, and the regulation of the temperature of the 
body, depend. As regards the former question, there can be no doubt 
that that degradation of tissue which results in the evolution of heat, 
although in itself a purely chemical process, is indirectly largely under 
the influence of the nervous system, and especially of its sympathetic 
portion ; for it is to this latter that the varying rapidity and force of 
the heart's contractions, and the varying diameters of the vessels 
(which between them affect so powerfully the molecular changes which 
are going on in the body) are due ; and it is by their direct operation, 
possibly, on the essential elements of glandular organs that the secre- 
tions of these organs are to a large extent regulated. The maintenance 
of the body at a uniform temperature is due to the existence of a re- 
markable power of adjustment between the amount of heat developed 
in the interior of the body, on the one hand, and the amount of cooling, 
on the other, which takes place during respiration by the admission of 
cold air and the exhalation of water, and at the cutaneous surface by 
radiation and perspiration — processes, however, which are again under 
the control of the nervous system. It need perhaps scarcely be added, 
that the equalization of the temperature of the body is dependent on 
the circulation of the blood ; that the more freely this takes place, the 
more does the temperature of the surface and of the extremities ap- 
proximate to that of the internal organs, while at the same time the 
more rapidly is the general cooling of the body effected ; but that, on 
the other hand, the more feeble the circulation, the cooler do the 
surface and the extremities become, the more exaggerated is the differ- 



108 MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



ence between the temperature of these parts and that of the interior of 
the body, and the more slowly does the internal temperature undergo 
reduction. 

The presence of abnormal or febrile temperature is usually attended 
with various symptoms and phenomena more or less characteristic of 
the febrile state. The skin becomes hot, the pulse accelerated, the res- 
pirations increased in frequency, the gastro-intestinal functions impaired 
or modified, the urine and other secretions diminished; and headache 
and muscular pains are complained of. There is generally also a 
tendency for the febrile phenomena to assume a remittent character, for 
paroxysms to recur once or twice it may be in the twenty-four hours 
— each paroxysm comprising three more or less distinctly marked 
stages, namely, a cold, a hot, and a sweating stage. In the first of 
these the patient feels chilly or cold, shivers or has rigors ; in the next 
his skin becomes hot and dry ; and in the third more or less abundant 
perspiration breaks out. 

The increase of temperature may vary from the slightest rise above 
the normal up to 110° or 112°. If it do not exceed 101°, slight fe- 
brile action only is present; if it vary between 101° and 103° the 
febrile condition may be regarded as " moderate;" if it vary between 
103° and 105°, the fever is considerable or "high;" if it exceed 105° 
the febrile disturbance is excessive and there is usually considerable 
danger; from 106° upwards the temperature is frequently termed 
hyperpyretic, and (with one or two notable exceptions) if it exceed 
107° or 108° death is almost certain to supervene. Febrile tempera- 
tures, like the normal temperatures, undergo variations ; and on the 
whole (excepting when interfered with by the influence of specific dis- 
eases) these variations correspond to the normal variations, but are 
exaggerations of them ; there is a matutinal fall, an evening rise, and 
the difference between them generally amounts to 2 or 3 degrees, but 
may be much more considerable. 

The skin is usually dry and hot ; but it is liable to considerable 
changes. Thus, not unfrequently, during the commencement of a fe- 
brile attack, or of a febrile paroxysm, while the internal parts of the 
organism are preternaturally hot, the vessels connected with the sur- 
face of the body and especially those of the limbs and head and face 
are so contracted as to allow comparatively little blood to reach the 
surface. This then looks shrunken and dusky, and may even in cer- 
tain parts, especially the hands, feet, nose, and ears, be considerably 
colder than natural. But more or less general heat of skin is present 
even when the surface displays this appearance of chilliness ; and 
before long the contracted vessels dilate, blood is admitted freely to 
the comparatively exsanguine parts, which then become plump, con- 
gested, dry, and often to the touch pungently hot. This latter con- 
dition is usually succeeded after a time by more or less copious perspi- 
ration. 

The frequency of the heart's beats is always increased ; and this in- 
crease has usually some relation to the temperature present. Thus, if 
the latter range from 100° to 101°, the pulse usually ranges from 80 
to 90; if the temperature from 101° to 103°, the pulse from 90 to 110; 



FEVER. 



109 



if the temperature from 103° to 105°, the pulse from 120 to 130. 
With still higher temperatures, the pulse may rise to 140, 160, 180, or 
over 200 beats in the minute. The rule, however, which is here laid 
down, is liable to frequent exceptions — especially in the case of irritable 
or nervous persons, in whom the pulse, in relation to temperature, is 
usually disproportionately frequent. The character of the pulse varies. 
In its typical condition it is more or less large, hard, and bounding, 
and its trace displays a sudden rise with an almost equally sudden fall 
and no indication of dicrotism. This is its condition during the height 
of fever. But during the cold stage it is small and hard ; and in the 
sweating stage large and soft. 

Although increase in the frequency of the respirations is undoubtedly 
one of the normal phenomena of fever, and it is not uncommon to find 
the respiratory acts rising to 30 or 40, and in the case of children to 
50 or 60, in the minute ; the respiration rate does not bear that close 
relation to the temperature that the pulse rate does. It is not uncom- 
mon to find the respirations normal in frequency even when the tem- 
perature is considerably elevated ; and, on the other hand, to find them 
greatly accelerated in febrile states of the mildest type. When the 
temperature becomes hyperpyretic or excessively high, the respirations 
are usually very rapid and shallow, and the inspirations attended with 
opening of the mouth and of the alse nasi, and with a sipping or suck- 
ing sound. 

Thirst is usually present, and often extreme ; and for the most part 
there is more or less impairment or loss of appetite; the mouth feels 
dry and clammy and acquires a bitter taste; and the tongue not un- 
frequently becomes more or less thickly coated, and sometimes dry. 
The bowels are generally constipated. 

The urine is almost invariably more or less obviously modified; it 
becomes scanty, high-colored, of high specific gravity, and deposits on 
cooling a more or less abundant sediment of urates and perhaps uric 
acid. But although the quantity of urine passed daily is generally far 
below the healthy average, the quantity of solid matter which is passed 
with it is usually far above the average. The chief increase here is in 
the urea, of which more than twice as much may be secreted as in 
health. Dr. Parkes has discovered 885 grains in the day's urine of a 
patient suffering from enteric fever, Alfred Vogel as much as 1235 
grains in that of one suffering from pyaemia, and Dr. Anstie over 1600 
in that from a case of pleuro-pneumonia. Uric acid is also increased, 
and may be increased twofold. Again the coloring matter of the urine 
may amount to three or four times the quantity discharged in health. 
In addition there is a more or less important increase in the quantities 
of hippuric, sulphuric, and phosphoric acids which are eliminated. 
On the other hand, chloride of sodium is diminished. Febrile urine is 
usually more acid than healthy urine. But although the fact of this 
general increase of the solid constituents of the urine has been well 
ascertained, it has also been well ascertained that occasionally, in the 
course of febrile disorders, the discharge of solid matters falls, some- 
times suddenly, sometimes gradually, far below the normal, the urine 
becoming pale, limpid, and of low specific gravity. Such occurrences, 



110 MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



however, are of temporary duration only, and are always followed 
sooner or later by an abundant discharge of effete matters which have 
been accumulating in the system. 

Among the febrile phenomena referable to the nervous system may 
be enumerated, headache, vertigo, delirium, a sense of weariness or 
soreness or aching in the loins and limbs, and alternations of subjective 
chilliness with flushes of heat. The sensation of chilliness is exceed- 
ingly common, and occurs most frequently at the beginning of a febrile 
paroxysm. It is often associated with rigors of more or less severity. 
Rigors are violent tremulous movements of all parts of the body — legs, 
arms, trunk, head, and neck — attended with chattering of the teeth and 
that duskiness or lividity of surface which has been already adverted 
to. The patient feels intensely cold, although the temperature of his 
general surface is probably far above the normal. Rigors appear to be 
due to the fact that, owing to undue contraction of its arteries, the 
skin receives less than its due share of blood, and less than its due pro- 
portion of the heat which is generated within the body. It is, there- 
fore, either generally or in certain parts relatively cold. During the 
presence of rigors the feet, hands, nose, and ears are often livid, 
shrunken, and actually cold. Rigors may not unfrequently be re- 
induced by exposing portions of the surface to the influence of the air. 
In children, convulsions sometimes take their place. 

There are one or two other points of interest in relation to fever 
which may be briefly referred to. First. It is a remarkable fact that, 
notwithstanding the extreme thirst of most fever patients, and the large 
quantities of fluid which they drink, but little fluid is discharged from 
the kidneys or bowels, and, as a rule, but little from the skin. Dr. 
Parkes suggests that this may be due to the presence in the system of 
some intermediate waste-product which, like gelatine, is powerfully 
hygrometric. Second. The condition of the blood is a matter of much 
interest, yet little of importance is known about it. It seems, how- 
ever, that after a time the red corpuscles and the albumen and the 
alkaline salts diminish in quantity — the blood consequently becoming 
impoverished. Third. That there is always excessive waste of tissue 
going on during fever is shown plainly enough by the condition of the 
urine, and by the gradual and often rapid emaciation of the patient, 
which takes place even if he be taking considerable quantities of nutri- 
ment. The tissues which especially suffer are the fat, which may almost 
entirely disappear, and the muscles, which dwindle away in a remarkable 
degree. But the more permanent tissues, such as the bones, also un- 
dergo some diminution. Fourth. The supervention of convalescence is 
described as taking place in two different ways, — either gradually by 
lysis, or suddenly by crisis. In the former case, all the febrile phe- 
nomena gradually disappear, and the patient lapses gently into con- 
valescence. In the latter case the progress of the attack is abruptly 
arrested with the appearance of a so-called " critical" discharge — 
copious perspiration, profuse diarrhoea, abundant secretion of urine 
loaded w T ith effete matters — by means of which it is supposed that the 
morbid blood rapidly purifies itself. Fifth. But fever may also end 
in death. This event, however, can rarely be attributed to the influence 



FEVER. 



Ill 



of fever alone, inasmuch as fever is always secondary to some specific 
or other disease of which it is a mere epiphenomenon or symptom. 
Nevertheless it is obvious, if we consider the physiological and other 
recognized consequences of fever, that fever itself tends to the induction 
of death in some two or three different ways. The chief of these ap- 
pear to be asthenia, blood-poisoning, and the direct influence of sus- 
tained high temperature. The continuous excessive waste of tissue, 
with the consequent gradual emaciation, loss of strength, and impair- 
ment of the functions of various organs, which is an essential element 
of the febrile state, must clearly, if it be not arrested, involve sooner 
or later a fatal issue. The progress of the hectic fever of phthisis, and 
of other chronic wasting disorders, furnishes a sufficiently apt illustra- 
tion. This waste of tissue necessarily also leads to the passage through 
the blood of an excessive quantity of effete products, such as urea and 
other matters related to urea in composition, some or all of w T hich are 
poisonous to the system in a greater or less degree. So long as these 
are freely eliminated by the emunctories, the blood may remain fairly 
pure, and but little mischief ensue. We have shown, however, that 
this elimination is sometimes arrested temporarily. There is no doubt 
that it is often insufficient to effect the purification of the blood. Under 
such circumstances uraemic poisoning and typhoid symptoms are only 
too apt to usher in a fatal issue. Lastly, the persistence of a tempera- 
ture above a certain elevation is incompatible with the maintenance of 
life. It has been shown by the experiments of MM. Delaroche and 
Berger that animals, placed in an atmosphere ranging from 122° to 
201° until the heat had killed them, were found at the time of death 
to have an internal temperature of only 11° to 13° above their natural 
standard; whence it may be inferred that an elevation to this degree 
is necessarily fatal to them. We do not of course know with any 
degree of accuracy what is the upper limit of temperature which is 
compatible with the maintenance of life in the human being. We may 
however say with some degree of assurance that a persistent tempera- 
ture above 110° will certainly cause death, and that there is good 
reason to believe that a temperature of even 107° cannot be supported 
for any length of time. Death from high temperature is attributed by 
M. Bernard to a condition of the heart analogous to rigor mortis ; the 
auricles are found full of blood, the ventricles contracted and empty. 
But the injurious influence of excessive heat is not exerted on the heart 
alone, but equally on all the living tissues, and especially probably upon 
the protoplasm wherever it is distributed. In cases of hyperpyrexia, 
the symptoms referable to the nervous system are particularly striking. 
They commence usually with more or less restlessness and confusion, 
and tendency to mental disturbance, and lead, through maniacal ex- 
citement or muttering delirium or convulsions, to coma and death. 
Nevertheless, it is by no means clear to what extent these symptoms 
are referable to abnormal heat. It is a remarkable fact that frequently, 
when the advent of death is attended with increasing elevation of tem- 
perature, the temperature of the internal parts continues to rise for 
some hours after death. 

It will be readily gathered from the foregoing discussion that the 



112 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



immediate cause of febrile temperature lies in the excessive degrada- 
tion of the tissues of the organism, and the consequent evolution of 
their latent heat. The abnormal activity of circulation and respiration 
which accompanies fever alone implies unwonted activity in some at 
least of the processes which these functions subserve ; and the progres- 
sive emaciation of the frame, and the continued presence in the urine 
(notwithstanding in many cases almost total abstinence from food) of 
an excessively large quantity of those matters which are the result of 
the degradation of albuminous compounds, clearly demonstrate the 
character of these processes. The above explanation obviously does 
not touch that further important question, " What is the cause of the 
tendency, which is always present in fever, to that preternatural ly 
rapid destruction and oxidation of tissue on which the febrile elevation 
of temperature depends?" This question, however, notwithstanding 
its importance, scarcely calls for discussion here. 

The thermometer has of late years become to the physician almost as 
important as the stethoscope. It is in general use, and is certainly of 
extreme value, not only in the diagnosis, but in the prognosis of 
disease. It is desirable, therefore, to make a few observations in 
reference to it. A clinical thermometer should be accurate, sensitive, 
should have its degrees divided into fifths, and be so marked as to be 
easy of perusal. It should also be furnished with an index, consisting 
of a single detached fragment of mercurv, measuring in the column 
between one-fourth and one-third of an inch long. For ordinary pur- 
poses an instrument, which may be carried in the waistcoat pocket in 
a case, and marked from 95° to 112°, is sufficient. It is well, how- 
ever, to be provided, for special purposes, with a thermometer of 
greater range (say from about 80° to 112°), and probably therefore 
of greater length and comparatively cumbersome. The index should 
never be allowed to descend into the reservoir and so to mingle with 
the rest of the mercury ; nor should supplementary indices be allowed 
to detach themselves from the mercurial column. The former acci- 
dent may be prevented by never violently shaking the index into the 
reservoir, and to some extent by the presence of an annular constric- 
tion in the channel of the thermometer a little above the reservoir ; 
the second, by always carrying the thermometer horizontal or with the 
reservoir downwards, and by never permitting the mercury when it 
has risen into the tube to be too suddenly cooled. Prior to taking a 
temperature, the index should be brought into the lower part of the 
tube, at least below the mark indicating the lowest temperature we are 
likely to meet with. The bulb of the instrument should then be 
placed in the part selected — in the axilla, beneath the tongue, in the 
anus or vagina — and retained there sufficiently long to permit of the 
rise of the mercurial column, and the carriage of the index to the posi- 
tion corresponding to the temperature of the part. It is important, 
especially as regards the axilla, that the bulb of the instrument should 
be tightly grasped, and entirely protected both from the influence of 
the air and from the contact of the clothes, and that it should be 
allowed to remain in situ from three to five minutes at least. A 
casual observation is of course often of considerable value; in many 



HECTIC FEVER. 



113 



cases, however, and especially in fevers and inflammations, periodical 
observations should be made. Sometimes morning and evening deter- 
minations of the temperature are sufficient for all practical purposes. 
But not unfrequently, especially in very severe and acute diseases, in 
certain specific diseases, or when the effects of certain forms of treat- 
ment are under investigation, periodical observations of much greater 
frequency are called for. 

Hectic Fever. — The term hectic is applied to those varieties of fever 
which attend various diseases of long duration, and more especially 
such affections as malignant disease, tuberculosis or chronic syphilis, 
which are characterized by the gradual development of proliferating 
growths in many organs, or such as caries of bones, disease of joints, 
and the like, in which purulent discharges are kept up for an indefinite 
period. 

The phenomena of hectic fever are essentially those which have been 
described in the preceding account of fever. They are chiefly peculiar 
in their comparative mildness and their long duration. The symptoms 
of hectic manifest themselves insidiously, and the febrile condition may 
be already far advanced before its presence is fully recognized. The 
patient probably finds himself gradually losing flesh and strength, and 
becoming disinclined for exertion ; he observes that he is disposed to 
be chilly in the morning; that in the evening, and in a less degree after 
meals, his hands and feet are hot and dry, and his face flushed ; and that 
he wakes towards the morning with a moist perspiring skin. But his 
tongue is clean, his appetite good ; and although he may be thirsty, and 
his pulse quickened, his other functions are properly discharged. At 
this time a careful thermometrical examination will probably show his 
temperature to be increased by two or three degrees. It will further 
show that, as in health, his temperature is lowest in the morning, 
highest in the evening, and that his indistinctly developed cold, hot, 
and sweating stages correspond pretty accurately with the usual cycle 
of the healthy temperature variations. 

As the morbid condition on which the fever depends progresses, the 
symptoms get (although of the same character as before) more distinctly 
developed, the patient becomes pallid, his emaciation and debility more 
obvious, and the febrile character of the affection more striking. The 
temperature, even now, often does not exceed 103°; but it is liable to 
occasional higher degrees of elevation, and in its matutinal remissions 
may even sink below the normal. The patient is apt to be chilly in 
the morning, with cold and livid feet, hands, and nose. In the evening 
exacerbation the skin becomes hot and dry, the palms and soles burn- 
ing hot, the lips dry and red, the cheeks flushed with a circumscribed 
red flush; and towards the morning he wakes to find himself drenched 
in profuse (colliquative) perspirations. The chief exacerbation almost 
invariably occurs in the evening, and it is often the only one; but there 
is occasionally a second earlier in the day; and generally the ingestion 
of food, and especially of an ample meal, is followed by more or less 
marked febrile reaction. With the progress of the other symptoms, 
the pulse becomes accelerated ; and even if it feels sharp, as it may do 
during the febrile exacerbations, it is positively enfeebled, and under- 



114 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



going progressive enfeeblement. Even now the tongue is most prob- 
ably clean, perhaps morbidly clean, and the appetite good. There is, 
however, more or less thirst, the bowels are probably constipated, and 
the urine (especially in the febrile paroxysms) more or less scanty, high- 
colored, and concentrated. 

At a later stage the symptoms become modified, and other phenom- 
ena (not wholly referable to the fever) superadded. The emaciation 
and debility get extreme, the pulse more and more feeble and rapid, the 
circulation imperfect; bed-sores form; the fingers become perhaps livid 
and bulbous, and the skin harsh and scaly; diarrhoea not unfrequently 
supervenes; the tongue gets dry and fissured or aphthous; the appetite 
fails; and death from exhaustion presently ensues. It is remarkable 
that in hectic fever the intellect is rarely affected, and that, in a large 
proportion of cases, the patient continues cheerful and hopeful even to 
the last. 

The Typhoid Condition. 

The condition here referred to, like fever, is common to many dif- 
ferent diseases. When erysipelas, carbuncle, pneumonia, or any other 
severe form of inflammation, is tending to a fatal issue; in the later 
stages of typhus, enteric fever, scarlatina, small-pox, and other specific 
fevers; towards the fatal close of acute atrophy of the liver, and of 
anaemia consequent on Bright's disease; and at the corresponding period 
of many other affections, typhoid symptoms, or symptoms resembling 
those of the later stages of typhus fever, are apt to supervene. 

The patient becomes excessively prostrate; he lies on his back in 
bed, with eyes closed, features shrunken and ghastly, and a dull stupid 
aspect, unconscious, or nearly unconscious of everything that is going 
on about him. His skin is dusky, moist, sometimes bathed in perspi- 
ration, yielding often a fetid odor, and for the most part, especially in 
the extremities or exposed situations, cold. His lips are dry, black, 
and probably fissured, his teeth loaded with sordes, his tongue dry, 
brown or black, and often contracted in all its dimensions. He has no 
inclination for food, and probably no material thirst, but a difficulty 
(partly due to the condition of his mouth) in swallowing and in utter- ' 
ance. His bowels are sometimes constipated, but often more or less 
relaxed, and the evacuations offensive. His respirations are shallow, 
but for the most part not much accelerated — ranging probably between 
twenty and thirty in the minute. They may, however, be much more 
frequent, and are liable to variation. The pulse is rapid and feeble, 
and tends to become more and more rapid and feeble, and towards 
the end imperceptible at the wrist, and irregular. It may vary at 
first from 100 to 120, but often attains a frequency of 140, or more, 
and at the same time assumes an undulating dicrotous character. 
The first sound of the heart is liable to become inaudible. It may be 
added that often shortly before death the superficial capillaries dilate, 
the blood accumulates and stagnates within them, the surface acquires 
a rosy aspect, and a profuse flow of perspiration takes place. Bed-sores i 
are apt to form upon the sacrum and other parts exposed to pressure. 
The condition of the urine presents considerable variety ; sometimes it 
is scanty, high-colored, and loaded with urates; sometimes, on the other * ' 



THE TYPHOID CONDITION. 



115 



hand, it is abundant, pale, and limpid, and of low specific gravity. 
Muscular debility is shown in the tendency which the patient has to lie 
upon his back, and to sink towards the bottom of the bed. His senses 
are blunted; he is often deaf; he takes little notice (even if his eyes 
are open) of surrounding objects; he rarely complains of pain or un- 
easiness, or acknowledges its presence, and is insensible to conditions 
which at other times would have caused much personal discomfort; his 
intelligence is impaired; his memory especially fails; his mind is full 
of delusions; and he is more or less constantly muttering — his condi- 
tion is that of low muttering delirium or typhomania. He can, how- 
ever, probably be recalled to himself momentarily if addressed loudly, 
and will then half open his eyes, endeavor to do what he is told to do, 
and even give an intelligent response; but he soon lapses into the con- 
dition from which he was aroused; he picks at the bedclothes; his 
limbs are tremulous when he endeavors to move them; and the mus- 
cular fibres are in constant vibratile movement, giving rise to the con- 
dition known as subsuttus tendinum; he passes his evacuations uncon- 
sciously, or allows the urine to accumulate in the bladder. With the 
advance of the typhoid symptoms, the mind becomes more and more 
obtuse, and the patient gradually passes into a state of stupor, and from 
thence into profound coma. The temperature presents great variety, 
dependent in a considerable degree on the nature of the disease on 
which the typhoid symptoms supervene. It is sometimes (as in Bright's 
disease) a good deal below the normal standard; sometimes, as in the 
hyperpyrexia of acute rheumatism, at an elevation of 110° or upwards. 
The typhoid condition is always one of great gravity, and in a large 
proportion of cases terminates in death. 

The collective phenomena of the typhoid state have generally been 
attributed to the presence of some poisonous matter in the blood. For- 
merly this was believed to be the specific virus of the disease in the 
course of which they became developed; or, in the case of local in- 
flammations, some morbific elements generated at the diseased spot and 
thence thrown into the circulation. It is difficult, however, to under- 
stand how it can happen that numerous poisons, distinct from one 
another, and having different actions in other respects, should yet 
have the common property of inducing the complex phenomena of 
the condition under consideration. Another view is now commonly 
entertained, and has far higher claims to acceptance than that which 
has just been considered. It is to the effect that the poisonous matters 
which circulate in the blood are not the specific elements of various 
diseases, but those products of the disintegration of the nitrogenous 
tissues — urea and the like — which are known, when accumulated in the 
blood, to have poisonous effects; and which are apt to accumulate in 
the blood in all those diseases in the course of which typhoid symptoms 
supervene. The excessive production of these effete matters in various 
forms of local inflammation and in the course of the infectious fevers 
has been firmly established ; and as regards some of the latter diseases 
it has been distinctly proved, not only that the kidneys (even when 
healthy) often fail to eliminate these matters in normal quantity, but 
that even when these organs act fairly well, the blood still remains 



116 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



overloaded with them; and further that, in patients who have died with 
typhoid symptoms, urea in excess has been discovered in the. blood. In 
chronic Bright's disease there is the same accumulation of urea and 
such like matters in the blood; and the typhoid symptoms which come 
on in the course of that disease have long been regarded as of ursemic 
origin. Indeed in this case it is impossible to suggest any other origin. 
The facts, of the presence of uraemia in all cases in which typhoid 
symptoms are present, and of the dependence of the typhoid symptoms 
in Bright's disease upon the condition of the blood, are almost conclu- 
sive in favor of the dependence of the typhoid condition generally upon 
urseinic poisoning. The circumstance that in some cases the accumula- 
tion of effete matters is due to their over-production, in others to their 
retention, does not in any degree tend to invalidate this conclusion. 

Collapse — Syncope. 

The states of collapse and syncope are in many respects the opposite 
of that of fever, and attended with either general or partial diminution 
of temperature. It is important, however, to observe that a general 
depression of the temperature of the body may take place, without any 
of the other symptoms of collapse being present, especially during the 
remissions of various febrile disorders, or the. period of convalescence 
from them; and that, on the other hand, profound collapse may occur 
while the temperature of the internal organs is still many degrees above 
the normal. 

The conditions under which collapse or syncope may supervene are 
very various. It may occur in the cases above mentioned, namely, in 
the periods of remission of febrile disorders, or in the course of con- 
valescence from them ; it may come on during rigors, or even when 
(as in cholera) a high internal temperature prevails ; it may be conse- 
quent upon the presence of urea, or of various extraneous poisons, in 
the blood. Other causes are mental emotions, more especially such 
as are of a depressing character; sudden and excessive pain ; unwonted 
distension of tubes (the urethra, the ureters, and the bile-passages, to 
wit) by foreign bodies ; rupture or perforation of internal organs ; haemor- 
rhage, and profuse discharges, especially from the bowels; vomiting; 
severe injuries of all kinds, including those due to the operation of irri- 
tant substances or poisons upon the stomach ; mechanical obstacles to 
the cardiac circulation, and so on. 

The symptoms of collapse are mainly the following : coldness and 
pallor of surface, more especially of the extremities and face, which 
appear shrunken, pinched, and occasionally livid; perspiration, more 
or less profuse, sometimes limited to the extremities and face, and 
generally forming large drops in this latter situation; infrequency of 
the respiratory acts, which are shallow, sometimes scarcely perceptible, 
often irregular, and now and then sighing or gasping ; feebleness of 
heart's action, indicated sometimes by increased frequency, sometimes 
by remarkable slowness of the pulse, which often becomes irregular 
and often scarcely perceptible or imperceptible at the wrist; occasion- 
ally hiccough and nausea, or even vomiting; extreme muscular debility; 



COLLAPSE — SYNCOPE. 117 

noises in the ears, indistinctness of vision, general soreness or sense of 
compression, want of breath, giddiness, depression or anxiety, and con- 
fusion of thought. In some cases there is considerable restlessness or 
transient delirium or maniacal excitement, sometimes slight convul- 
sions, sometimes complete insensibility ; in some cases, on the other 
hand, the patient's mental condition is wholly unimpaired from first 
to last. In severe cases the patient lies almost motionless, with eyelids 
half closed and perhaps slightly twitching — looking like a corpse. 
In true collapse there is probably always more or less marked fall of 
temperature; and that is the case even when, as in the collapse of 
cholera and other febrile disorders, the internal temperature is still 
abnormally high* But in all cases the extremities and the head lose 
heat rapidly, and usually become positively cold. In cholera, the 
thermometer in the mouth or axilla may stand at 90° or less, while 
that in the rectum marks 105° ; and in collapse, the result of severe 
injury, the temperature even in the rectum may fall (as is shown by 
Mr. Wagstaffe) as low as 82.15°. Much more commonly, however, 
collapse-temperatures range between 92° and 97°. 

Syncope differs from collapse (of which, indeed, it is a mere variety) 
mainly in the suddenness of its access, and the rapidity of its progress, 
but generally also in the fact that the symptoms of syncope, during 
their continuance, are more severe than those of collapse. This latter 
distinction is, however, by no means essential ; for, as is well known, 
faintness or syncope may present all degrees of intensity, from a simple 
sense of faintness to prostration so profound as to simulate death. 
The shortness of the duration of syncope necessarily precludes the 
occurrence of any marked depression of the general temperature. 

When recovery from collapse or syncope takes place there is always 
more or less reaction ; the surface becomes smooth, its color returns, 
and a general glow supervenes, the circulation becomes more active, 
the temperature rises, and other febrile phenomena manifest them- 
selves. And if the collapse has been profound and of long continuance, 
the consecutive fever may assume serious proportions. 

In considering the pathology of collapse there are three factors of 
that condition the importance of which becomes especially obvious. 
These are — depression of temperature, feebleness of circulation, and the 
condition of the nervous functions. 1. The depression of temperature, 
so far as regards the limbs, face, and other exposed parts, can no 
doubt be traced mainly to the comparative failure of the circulation 
in them. But that this is not the sole cause of that depression is 
obvious from the fact that the internal temperature, instead of rising, 
as under such circumstances it should do normally, itself tends to 
diminish, and sometimes diminishes rapidly. It is clear, indeed, that 
there is throughout the organism a more or less complete arrest of those 
disintegrating processes upon which the maintenance of the tempera- 
ture of the body depends, and presumably also a more or less complete 
arrest of those vital processes with which these latter are intimately 
interwoven. 2. The feebleness of the circulation is shown by the 
obvious weakness, and often irregularity, of the heart's action, by the 
failure, more or less complete, of the pulse at the wrist and in other 



118 MECHANICAL AND FUNCTIONAL DERANGEMENTS. 

peripheral situations, and by the concurrent disappearance of blood 
from the cutaneous surface and other textures. The details of the 
processes by which the failure of the circulation is induced, differ 
doubtless in different cases. It may, however, be assumed that there 
is always cardiac debility, and in a large proportion of cases diminished 
supply of blood to the left side of the heart, and hence to the vessels 
which it supplies. In collapse from haemorrhage the latter condition 
is of extreme importance. And indeed it is found that in a large pro- 
portion of cases of death from syncope or collapse the cavities of the 
right side of the heart are distended, while those of the left side, and 
more especially the ventricle, are contracted and empty. In other 
cases, however (especially if death has been quite sudden), the left 
cavities may be found overloaded. 3d, and most important, is the 
condition of the nervous functions. We have pointed out the not 
unfrequent dependence of collapse or syncope on affections of the mind, 
and on many other conditions which can only be operative through the 
medium of the nervous system ; and we have enumerated the various 
phenomena, referable to the nervous system, which attend and charac- 
terize a large proportion of cases.. These facts are sufficiently sug- 
gestive. But when we look a little more closely into the matter, and 
consider how many different causes, of different operation, equally 
produce the same collective phenomena of collapse ; how rapidly these 
phenomena supervene, and how universally the organism is affected 
by them ; how impossible it seems that a smash of the leg, or a perfora- 
tion of the bowel, or an agony of terror, should directly arrest the 
chemical changes going on throughout the organism, and so reduce the 
temperature of the body, or should directly influence the action of the 
heart and arteries, it is impossible to doubt (what many other consider- 
ations tend to prove) that all the phenomena of collapse are directly 
traceable to the operation of the nervous system — not, however, of the 
brain or of the cord, but of that department, namely, the sympathetic, 
which presides over circulation, nutrition, and the due performance of 
the functions of the various organs, including those of the brain itself. 

Death. 

Death is one of the natural terminations of disease ; and according 
to the nature of the disease, or the office, bulk, or position of the organ 
which may be its seat, the phenomena which usher in that event vary 
in a greater or less degree. Many of the specific fevers prove fatal 
with the supervention of typhoid symptoms; many exhausting diseases 
induce death by simple debility or asthenia, and other affections by the 
allied conditions. of syncope or collapse; diseases of the air-passages or 
lungs prevent the due aeration of the blood, and are fatal by asphyxia ; 
renal affections lead to the accumulation of urea in the blood, and death 
by uraemic poisoning ; and diseases of the brain induce coma, from 
which death presently results.. In a large proportion of cases, no doubt, 
various morbid processes concur in the induction of the fatal issue. 
Nevertheless a careful consideration of the phenomena of death enables 



DEATH. 



119 



us to bring the different modes of dying, numerous as they may at first 
appear to be, into a comparatively small number of distinct groups. 

Bichat, in his Reeherches sur la vie et la mort, speaks of death begin- 
ning at the head, death beginning at the heart, and death beginning at 
the lungs. It is obvious, however, that these are not the only organs 
from which death commences ; and even those who follow Bichat most 
closely find it necessary to adopt his views with some modification or 
addition. To us it appears that the principal sources of somatic death 
are to be found: 1st, in failure of nutrition; 2d, in failure of the cir- 
culation of the blood; 3d, in failure of the emunctories to effect the 
elimination of effete and poisonous matters ; and 4th, in failure of the 
nervous system to perform its appropriate functions. 

1. Death from Failure of Nutrition. — This may be due to many cir- 
cumstances, and arise in the course of many diseases. It may depend 
on actual deprivation of food, as in starvation, or obstructive disease 
of the oesophagus or cardiac orifice of the stomach ; or on persistent 
vomiting or diarrhoea, or any other affection (structural or functional) 
of the alimentary canal, which interferes with the proper absorption 
of nutritious matters at the mucous surface ; it may depend on the 
presence of diabetes or of rapidly-growing malignant tumors in which 
there is a misappropriation of the nutriment received into the blood ; 
it may depend on the presence of inflammatory processes or febrile dis- 
orders in which excessive waste of tissue takes place without equivalent 
reconstruction ; and, lastly, it may be referable to the continuance of 
wasting discharges or of losses of blood. The symptoms which pre- 
cede death from these causes depend largely upon the conditions under 
which they arise, and are therefore liable to considerable variation. 
But such as are specially referable to innutrition are, more or less 
rapidly increasing emaciation and debility, mental languor, feebleness 
of circulation, and inability to resist the influence of external cold. 
The general emaciation is not always proportionate to the muscular 
debility, which, after a while, becomes extreme. The patient probably 
lies upon his back, motionless or almost motionless, with hands, feet, 
nose, and ears probably cold and dusky ; breathing feebly and at long 
intervals, with the pulse barely perceptible at the wrist; sensible, but 
dull and languid, taking little notice, and not even caring to restrain 
the escape of his evacuations. With possibly no addition to the symp- 
toms the general feebleness passes almost insensibly into death — the 
last indication of life being furnished by the barely perceptible move- 
ments of the heart. In simple starvation there is a general lowering 
of temperature, which previous to death becomes considerable. Here 
life may sometimes be maintained for awhile by the application of suffi- 
cient warmth. In disease, however, although loss of temperature is 
not unfrequent, rise of temperature, under certain circumstances, is of 
common occurrence. 

2. Death from Failure of the Circulation. — The failure may commence 
in various situations, arise from various causes, and come on with 
various degrees of rapidity. It most commonly takes place at the 
heart, which ceases to propel the blood, either from actual inability or 
failure to contract upon its contents ; or from spasmodic contraction 



120 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



which opposes the entrance of blood into it; or from the compression 
exerted upon it by accumulation of serum or of blood in the pericardial 
Cavity ; or from the obstruction of one of its orifices by clot, or some 
other equivalent cause. It may also depend upon obstruction in the 
pulmonary arteries, either by thrombosis or embolism; or upon general 
contraction of the smaller branches, as occurs in asphyxia; or upon 
similar contraction of the smaller systemic arteries, as probably hap- 
pens in angina pectoris. Death from the cause here referred to may 
take place quite suddenly — the patient becoming faint and falling down 
insensible, and with a gasp or a convulsive tremor yielding up his 
breath. It may take place less suddenly, yet still rapidly — the patient 
becoming pale, cold, bedewed with perspiration, insensible or nearly so, 
and possibly convulsed, with slow and shallow or, it may be, gasping 
respiration, extreme feebleness of the heart's action, and imperceptible 
pulse. When the process of dying from failure of the circulation as- 
sumes a more chronic form the phenomena of collapse are doubtless 
always present in a greater or less degree, and there is a tendency, 
more or less obvious, to depression of temperature; but in addition, 
the blood tends to accumulate and to become stagnant in the capillaries 
and veins; dropsy and congestion, with extravasation of blood, are apt 
to take place; and not unfrequently the parts furthest removed from 
the influence of the heart (nose, fingers, toes) become gangrenous. Cer- 
tain differences in the details of dying depend, no doubt, on the situa- 
tion in which obstruction occurs. It is stated that, if it take place sud- 
denly on the right side of the heart or in the trunk of the pulmonary 
artery, extreme dyspnoea is one of the prominent symptoms. If on the 
other hand, the sudden obstruction occur on the left side, insensibility 
and convulsions will probably be amongst the earliest of its conse- 
quences. Further, if gradual impediment arise on the right side of the 
heart or in the course of the pulmonary artery or its branches, more or 
less over-accumulation of blood will speedily ensue in the systemic 
veins and capillaries; if such impediment arise on the left side of the 
heart, the consequent congestion will first involve the pulmonary 
vessels. 

3. Death from Failure of the Elimination of Effete and Poisonous 
Matters- — The poisonous matters, to which reference is here specially 
made, are those which accrue in the course of the disintegrating and 
secretory processes which are always going on, and are mainly there- 
fore carbonic acid, which is evolved by the lungs ; urea and other 
nitrogenous matters which are discharged by the kidneys ; and some 
of the constituents of the bile, which are formed in the liver and under 
certain circumstances absorbed into the circulation. The retention of 
carbonic acid in the blood produces the condition which is commonly 
known as asphyxia, but is more correctly termed apnoea, and might 
perhaps be still better designated anthracsemia. It may arise in various 
ways: from obstruction of the larynx or trachea; from bronchitis or 
other forms of obstruction in the bronchial tubes; from disease of the 
lungs; from mechanical impediment to respiration, such as maybe 
produced by accumulation of fluid in the pleural cavities; by paralysis 
or spasm of the muscles engaged in respiration ; or by deficient supply 



DEATH. 



121 



of atmospheric air. The symptoms of sudden asphyxia are manifested 
in their typical completeness in cases of drowning, or of choking by 
the intrusion of a solid mass into the upper part of the larynx. The 
sense of dyspnoea is extreme, and violent but futile efforts of the res- 
piratory muscles take place. But soon vertigo comes on, the respira- 
tory agony diminishes, and the efforts at inspiration become less violent. 
Gradually unconsciousness supervenes, convulsive movements may 
occur, and in the course of a few minutes all muscular action ceases. 
The heart continues to beat for a minute or two perhaps after respira- 
tion has come to a standstill. During the progress of suffocation the 
non-arterialized blood becomes impeded in its transit both through the 
small arteries and capillaries of the lungs and through the correspond- 
ing systemic vessels, and the pressure of the blood in the systemic ves- 
sels becomes consequently augmented. But gradually, the obstruction 
becoming more and more complete in the vessels of the lungs, less and 
less blood reaches the left cavities of the heart, and less and less is hence 
propelled into the arteries; which also by gradually contracting on 
their contents slowly drive them onwards into the veins. By these 
means a large accumulation of blood takes place in the systemic veins, 
right side of the heart, and pulmonary arteries; while the pulmonary 
veins, left cavities of the heart, and systemic arteries become compara- 
tively empty. During the progress of the phenomena above described 
the surface becomes more and more livid and swollen, and the super- 
ficial veins more and more obviously distended. But poisoning by 
carbonic acid takes place, in the course of many diseases, much more 
gradually, and may extend over a period of days, weeks, or months. 
The general phenomena are, in such cases, essentially the same as those 
which have just been detailed, but they are, as it were, more diluted 
and of less intensity. The surface becomes dusky or livid and cool, 
the veins distended, the right side of the heart dilated, the pulse quick, 
feeble, intermittent ; there is more or less distressing dyspnoea and 
anxiety. But gradually the struggle for breath grows less painful and 
violent, the patient becomes drowsy, and begins to ramble, and then, 
passing into a condition of more or less profound coma and general de- 
bility, gradually sinks. The accumulation in the blood of urea and other 
matters, which should be eliminated by the kidneys, leads to many im- 
portant consequences. By their slow action they induce more or less 
marked ansemia, contraction of the smaller systemic arteries, hyper- 
trophy of the heart, and dropsy, with, sooner or latter, impairment of 
the nervous functions, and especially delirium, eclampsia, and coma. 
It is to them also that are mainly due the collective phenomena to 
which the name of " typhoid condition" has been given, and which (as 
has been already pointed out) are apt to come on in the course of va- 
rious febrile disorders and in structural diseases of the kidneys. 

4. Death from Failure of the Nervous System to Perform its Appro- 
priate Functions. — Diseases of the nervous system are fruitful sources 
of death. Coma is not only a frequent precursor of death in cases in 
which the brain is not primarily involved, but it is a common symp- 
tom of grave cerebral lesions. In coma there is profound unconscious- 
ness, the patient breathes slowly, irregularly, and stertorously, the saliva 



122 



MECHANICAL AND FUNCTIONAL DERANGEMENTS. 



and other secretions from the mouth, throat, and air-tubes accumulate in 
these several passages, and are not expelled ; and gradually, partly from 
this cause, partly from failure of the respiratory muscles, the patient dies 
of asphyxia or apnoea. Spasm again, or motor paralysis, may equally 
produce death by apnoea. In epilepsy spasm of the glottis, in tetanus 
spasm of the muscles of respiration, may stop the breath and asphyxiate 
the patient; and the like result may ensue on paralysis of the muscles of 
the throat and larynx, or of those that govern the movements of the 
chest. But in these cases it is obvious that, although death may be said 
to begin from the brain and cord, the patient dies in reality of carbonic 
acid poisoning. In truth, however, it is not the brain and cord, but 
the sympathetic system of nerves, which has the direct control over the 
functions the sum of which constitutes life. It is this which has within 
its grasp, so to speak, the whole of the circulatory system, the excre- 
tory, secretory, and nutritive processes, and even the functions of the 
brain itself; and it is to this system, therefore, that we should especi- 
ally refer when we speak of death commencing from the nervous system. 
It is to the influence of this system that both paralysis and spasmodic 
contraction of the heart and bloodvessels are due ; it is to the influence 
of this system alone that the phenomena of shock or collapse (which 
have been previously described) are directly referable. 

Now, although we have in the foregoing paragraphs distinguished 
several modes of dying, or groups of processes by which death is in- 
duced, it is obvious, if we come to compare them among themselves, 
that they present much that is in common, and tend to merge the one 
into the other. Thus, death from coma, or from tetanic spasm, resolves 
itself eventually into death from asphyxia, and death from asphyxia 
into death from arrest of the circulation of the blood, and this arrest of 
the circulation of the blood into spasmodic and insuperable contraction 
of the pulmonary arterioles, which in its turn is referable to the in- 
fluence of the vaso-motor nerves. And, indeed (excepting probably in 
those cases in which death is induced by the sudden cessation of the 
heart's contractions under the influence of shock) the last obvious efforts 
of life are those of the heart ; the patient becomes unconscious, the 
respiratory efforts cease; yet still we listen for the sounds of the heart, 
and only when these finally disappear consider life extinct. But in 
neither shock nor asphyxia, does the heart (at all events as a rule) 
cease to act because its muscular parietes have wholly lost their apti- 
tude for contracting. In the former case the heart is, as it were stunned, 
and may yet under the influence of artificial respiration, have its move- 
ments re-established ; and in the latter case, where the heart seems to 
cease from sheer debility, this debility is rather in the ganglionic cen- 
tres and nerves, which fail to supply the accustomed stimulus, than in 
the muscular tissue itself, which may still be made to contract under 
the influence of artificial stimulation. It would hence seem to follow 
that while, as a rule, the cessation of the heart's beats may be regarded 
as the last observable phenomenon of life, this cessation, as well as that 
of many other of the phenomena of organic life, may in their turn be 
referred to the sympathetic system. 



HYGIENIC TREATMENT. 



123 



THE TREATMENT OF DISEASE. 

Details of treatment are discussed, with more or less fulness, under 
the heads of the various maladies which are described later on in this 
volume. There are,' however, some general principles involved in the 
treatment of disease which it will be convenient to touch upon briefly 
here. They come mainly under the heads of Hygiene, Prophylaxis, 
and Remedial Treatment. 

Hygienic Treatment. — By the term Hygiene is meant the science of 
health, or the study of those conditions on which the maintenance of 
health depends. Hygiene, therefore, takes cognizance of the sanitary 
influences of the atmospheric and telluric circumstances which surround 
us; of the conditions, especially in relation to density of population, 
ventilation, drainage, and cleanliness, in which we live; of the water 
and of the food which we swallow ; and also of our dress and of our 
personal habits. The immense importance of attention to this depart- 
ment of medicine is beyond dispute; yet the subject is so vast, the de- 
tails which it involves so innumerable, that it would be out of place to 
engage in their discussion in such a work as the present. But atten- 
tion to the laws of hygiene is not less important for the welfare of the 
sick and convalescent than it is for the welfare of those who are as yet 
in the enjoyment of good health; and indeed it not unfrequently hap- 
pens that it is to hygienic measures, rather than to drugs, that we must 
look for the cure of our patients. Even in this restricted sense the sub- 
ject of hygiene is too extensive to admit of satisfactory discussion within 
the limits of space at our disposal. It must be sufficient to refer (by 
way of example) to the important beneficial influence which a mild 
balmy air exerts upon those who are suffering from inflammatory affec- 
tions of the respiratory organs, or from pulmonary phthisis, and upon 
those who are convalescent from many forms of disease; to the injury 
which cold winds or variable weather inflicts on rheumatic patients; to 
the essential importance of treating the sick in airy, well-ventilated 
apartments, and of yet securing an equable genial temperature, of main- 
taining perfect cleanliness of the patient's person and of everything 
around him, of removing at once from his chamber all evacuations 
and other offensive matters, of taking care that the water which he 
drinks is free from unwholesome impurity, and the food which he 
takes is of good quality ; and, as regards those who are suffering from 
illnesses which do not necessitate confinement to the house, or those who 
are recovering, to the need for seeing that their dress is sufficiently pro- 
tective against the weather, that they are not intemperate in meat or 
drink, and that they do not keep bad hours or indulge in any other 
habits which are or may be hurtful. The exigencies of different mala- 
dies call for more or less important modifications in the employment of 
hygienic measures. These, however, are points which will, so far as is 
necessary, be dealt with subsequently. 

Prophylactic Treatment. — By Prophylaxis is signified the preventive 



124 



THE TREATMENT OF DISEASE. 



treatment of disease. In some respects this subject may be regarded 
as a part of hygiene, in some as a part of ordinary remedial treatment. 
We prefer, however (mainly for convenience of discussion), to look 
upon it as distinct from both. We understand by it the adoption of 
special measures to prevent the outbreak of special diseases which 
threaten, or the supervention of anticipated dangers in the course of 
diseases, and shall briefly consider it under the following heads. 

1. Prophylaxis in Relation to the Tendency, Inherited or Acquired, to 
Disease. — We know that many persons derive from their parents pro- 
clivities towards certain diseases, such as phthisis, gout, epilepsy, and 
insanity. We know also that many of these affections may be induced, 
in those who are free from taint of inheritance, by circumstances which 
tend to impair the health. We know, further, that exposure to simi- 
lar conditions is peculiarly apt to act injuriously on those in whom the 
tendency already exists. And hence the importance, which is fully 
recognized, of adopting precautionary measures in reference to such 
persons; of sending the patient, in whom phthisis threatens, to an 
equable climate, of restricting the diet and especially of curtailing the 
alcoholic drink of him who has reason to anticipate gout, and similarly 
with reference to many other affections. Further, there are various 
diseases of which one attack imparts a liability to subsequent attacks : 
such are rheumatism, erysipelas, and other inflammations, ague, and 
intermittent hematuria. It is obvious that here, again, it is of the 
utmost importance, for the welfare of the patient, that he should be 
protected from those injurious influences which he knows by experience 
to be the sources of his malady. 

2. Prophylaxis in Relation to Parasitic, Endemic, and Infectious 
Disease. — Many parasitic diseases are developed under circumstances 
which are well understood. Tapeworms are mainly derived from the 
ingestion of the insufficiently cooked flesh of oxen and pigs, and the 
trichina spiralis from the ingestion of that of the latter animal ; the 
Guinea-worm and the Bilharzia both prevail in certain regions. It is 
needless to dwell on the importance which the knowledge of such facts 
has in reference to the prevention of maladies of the kind. Endemic 
diseases are due to the operation of local causes, a knowledge of which, 
or of their distribution, clearly furnishes an important clue to their 
prevention. Thus ague prevails in certain regions, goitre and cretinism 
in others ; and in both instances the occurrence of disease may be pre- 
vented by removal to some more salubrious district. In the former 
case, indeed, the malarious poison may be eliminated or destroyed by 
the construction of effectual drainage. Amongst endemic affections 
may be included ergotism from the use of spurred rye as food, lead- 
poisoning from the use of lead-infected water, and the like, against 
most of which the suitable prophylactic measures are sufficiently ob- 
vious. Epidemic diseases are probably always directly or indirectly 
contagious; but the several poisonous matters or contagia to which 
their spread is due, are thrown off by different parts of the organism, 
gain an entrance into the system by different portals, and present in 
other respects essential differences of habit. The knowledge that the 
contagium of typhus becomes especially virulent in the presence of over- 



REMEDIAL TREATMENT. 



125 



crowding, that that of relapsing fever has some special relation with 
starvation, is of great importance in reference to the measures which 
should be adopted in order to prevent the development or to arrest the 
spread of these diseases; the knowledge that measles is in the highest 
degree contagious previous to the occurrence of rash, that scarlet fever 
is comparatively little contagious during the corresponding period, or 
even for a few days subsequently to the appearance of the rash, is also 
of importance in reference to the management of these affections; again, 
the knowledge which we now possess that, while most of the exanthem- 
ata are propagated through the atmosphere by the breath or cutaneous 
emanations, cholera and typhoid fever are only infectious through the 
intestinal excreta, and their poisons received into the system mainly by 
means of contaminated drinking-water, supplies us with practical data 
as to the methods by which their outbreaks should be dealt with, which 
are of the highest value. The fact that in most of the diseases coming 
within the epidemic class, one attack is protective in a greater or less 
degree against future attacks, is also of great importance in relation 
to prophylactic medicine. 

3. Prophylaxis in Relation to the Complications or Sequelce of Dis- 
ease. — Most diseases bring in their train liabilities to specific incidents 
of more or less gravity — a fact, the knowledge of which enables us in 
many cases to take early measures for their prevention or alleviation. 
The knowledge that rheumatism is apt to involve the pericardium or 
the valves of the heart; that in scarlet fever renal inflammation, albu- 
minuria, and anasarca are liable to supervene; that in enteric fever 
perforation of the bowel may take place at certain stages of the disease ; 
that in gonorrhoea the eyes may become infected and destroyed, enables 
us, in dealing with these affections, to take precautions which are often 
successful against the supervention of the mischances which have been 
enumerated. 

The Remedial and Therapeutical Treatment of Disease. — The great 
aim which the medical man places before himself is the cure of disease. 
Unfortunately, however, a direct cure, at all events a direct cure by 
means of drugs, is in the great majority of cases totally impossible. 
We may, in the case of some parasitic affections, and more especially 
of those which affect the surface of the body, kill or expel the parasites 
and so restore the patient to health ; we may, by surgical operation or 
other mechanical measures, get rid of foreign bodies or concretions 
from internal cavities or canals, remove diseased parts, discharge the 
accumulated contents of normal or of abnormal cavities, reinstate dis- 
placed organs, dilate contracted channels, or, failing this, make new 
openings above the seat of obstruction, and so furnish passages for the 
habitual escape of matters that need to be evacuated ; and we may in 
a small number of cases by the use of specific medicines materially 
alleviate, and it may be absolutely cure, certain diseases — by arsenic 
or quinine ague, by mercury syphiiis, by colchicum gout, by iron chlo- 
rosis ; or, by the adoption of a suitable diet, cure scurvy, and possibly 
rickets and some other offections. But we cannot, either by mechani- 
cal measures, or by specific drugs, or by the restoration to the dietary 
of matters in which it has been wanting, cure the infectious fevers, or 



126 



THE TREATMENT OF DISEASE. 



internal inflammations, or carcinoma, or degenerative changes, or many 
of the functional and other disturbances to which the organism is 
liable. Most of these affections indeed take a course peculiar to them- 
selves, tending in some cases towards ultimate recovery, in some to- 
wards chronic ill-health, in some towards speedy death. We can do 
little, often nothing, to arrest them in their progress, or to put limits 
to their duration. And all that probably remains to us is, by main- 
taining the patient's strength, by relieving symptoms, and by taking 
precautions against the supervention of complications or accidents, to 
enable him to pass with comparative safety or comfort through his 
malady — hastening convalescence if the disease be one that does not 
necessarily end fatally, postponing the final issue if the disease be in 
the nature of things mortal. The chief general indications under such 
circumstances seem to be: 1st, to protect the patient from injurious 
influences; 2d, to support his strength by appropriate nourishment; 
3d, to maintain or to restore the healthy tone of the nutritive functions ; 
4th, to promote the free action of the emuoctories; 5th, to relieve the 
secondary phenomena or the symptoms of the disease ; and, 6th, to ob- 
viate the tendency to death. 

1. The protection of the sick from injurious influences is obviously 
a matter of very considerable importance. No one would dream of 
exposing a patient with rheumatic fever or acute laryngitis, or indeed 
with any intrathoracic inflammation, to cold air or vicissitudes of tem- 
perature; or, on the other hand, of covering up a small-pox or typhus 
patient with an accumulation of bedclothes, and placing him in a 
stuffy, ill -ventilated room. But different diseases are obnoxious to 
different injurious influences, and need therefore in this respect different 
kinds of management. Under any circumstances patients should 
always be kept as clean and as dry and as free from undue pressure or 
friction as possible, and should not be allowed to soak in their own 
discharges ; for in a large number of cases, and particularly in those 
of chronic wasting diseases, of inflammatory and of febrile disorders in 
the typhoid stage, and of paralytic affections of the central nervous 
organs, there is a peculiar aptitude, especially under such circum- 
stances, for the speedy production of bed-sores. 

2. The maintenance of the patient's strength by the judicious 
administration of food is an essential element in the successful treat- 
ment of disease. In most diseases the tissues of the body disintegrate 
with unwonted rapidity, and emaciation and debility tend to supervene 
in a proportionate degree ; and in most this over-rapidity of disintegra- 
tion is accompanied with loss of appetite, or loathing of food, or im- 
pairment of the nutritive functions, or some other condition which 
renders it difficult or impossible to supply to the organism the 
alimentary matters necessary for its renovation and maintenance. If 
the obstacle lies in the patient's determination not to take food, as is 
the case with some lunatics, food must be administered by means of 
the stomach-pump; if it depends on some mechanical impediment in 
the oesophagus, stomach, or elsewhere, the food must be administered 
in such a form (for the most part fluid), and in such quantity, as will 
permit of its comparatively easy transmission through the constricted 



REMEDIAL TREATMENT. 



127 



or compressed or paralyzed part; failing such measures, operative pro- 
| cedure of some kind or other may under certain circumstances become 
advisable. If the patient's inability to take food depends upon irrita- 
bility of the stomach, this condition must be remedied by appropriate 
treatment, and all food administered meanwhile must be nutritious, 
unirritating, easy of digestion, and given in small quantities, and, if 
! possible, frequently. Milk, barley-water, gruel, and the like are 
1 generally most suitable for such cases. Occasionally, however, small 
quantities of solid but well-comminuted food are preferable. If the 
■ patient be suffering from inflammation, or fever, or other constitutional 
! conditions, in which utter abeyance of all desire for food exists (asso- 
ciated as such abeyance often is with more or less irritability of the 
I stomach, and even with difficulty of swallowing), it is generally advis- 
j able, hi order to insure the due administration of nutriment, to draw 
up some scheme for the guidance of the nurse or other attendants ; to 
determine how much food it is desirable to administer in the twenty- 
four hours, the intervals at which it should be supplied, and the 
quantity which should be given on each occasion. A teacupful or a 
wineglassful, or a tablespoonful of fluid nourishment may, according 
to the nature of the case and the circumstances which arise, be directed 
to be administered every two hours, or hour, or half hour. The 
quantity given at one time should never (if it can be avoided) be so 
large as to cause sickness ; and the frequency of administration must 
be regulated in some measure by the quantity which is given at each 
meal ; but we must not be disheartened if we find (as is too often the 
case) that the patient is unable to take the whole amount of nourish- 
ment which we have determined upon as his minimum allowance. In 
cases of this kind nothing can, as a rule, be better than milk ; and 
generally even those with whom it habitually disagrees can now take 
it with little difficulty ; but it is often necessary to alternate its use 
with that of other nutritious fluids, such as gruel, barley-water, rice- 
water, arrowroot, corn-flour or biscuit-powder properly prepared with 
water or milk, or beef tea, mutton-broth, chicken-broth or soups, or to 
replace it by them. Alcohol, in some form or other, is frequently 
necessary, and must then take its place in the rota. In all cases, 
whether of inflammation or fever, or of gastro-intestinal affection, or of 
mechanical obstacle to the entrance of food into the stomach, if the 
amount administered by the stomach is insufficient to maintain life, 
nutritious enemata must be systematically given ; and, indeed, this 
mode of administering food may sometimes be temporarily employed 
with great benefit, to the total exclusion of that by the mouth, in cases 
of extreme irritability of the stomach. In many chronic diseases, such 
as pulmonary phthisis, the appetite often remains good, though perhaps 
variable and capricious, and hence it is a comparatively easy task to 
insure the due administration of nourishment. The appetite is gen- 
erally good also during convalescence from wasting disorders, and for 
the most part may be taken as an indication that the patient needs to 
be well fed. Although the rules above laid down are generally true, 
there are occasional exceptions to them ; and moreover special diseases 
. in some cases need special modifications of diet. A day or two of 



128 



THE TREATMENT OF DISEASE. 



abstinence or of starvation is often beneficial, sometimes imperative; 
and, again, the importance is obvious of the avoidance of amylaceous 
matters by diabetic patients, and of excess of nitrogenous food by those 
who are suffering from Bright's disease. It may be added that patients 
frequently come under our care who are suffering not only from dis- 
ease, but from starvation, which may have commenced prior to the 
commencement of their disease or supervened upon it; and that here 
especially the good effects of careful attention to the nutritive functions 
are often strikingly exemplified. 

3. It has been already hinted, in the foregoing paragraph, that it is 
in many cases essential for the successful administration of nourishment 
that the stomach and alimentary canal should be first rendered capable 
of retaining and acting upon the alimentary matters which are intro- 
duced into them. It is, in fact, always important, in the presence of 
disease, to maintain, or as far as possible to improve, the general con- 
dition of the nutritive functions. To some and indeed to no incon- 
siderable extent this end may be attained, as we have pointed out, by 
the judicious administration of food. But in a large proportion of 
cases tonic medicines of various kinds are of extreme efficacy in this 
respect. It is needless to point out the numerous cases in which iron, 
cinchona, cod-liver oil, and the like act almost as specifics in the cure 
of disease. We wish, however, particularly to insist on their value in 
the treatment of many other morbid conditions, in reference to which 
they do not possess obviously specific powers. Among these we may 
name the various forms of dropsy, and many other consequences or 
secondary phenomena of organic lesions of the heart, lungs, liver, kid- 
neys, and other organs. In such cases, it is generally necessary to 
adapt the form of tonic to the condition of the alimentary canal, or it 
may be to associate with it medicines which tend to soothe or stimulate 
or otherwise act beneficially on the mucous membrane. 

4. The notion of getting rid of the poisonous elements of disease, by 
eliminating them by the various emunctories or other routes, is an old 
one. It happens, however, unfortunately, that we have as a rule little 
or no power in thus discharging the proximate causes of disease. It 
is entirely beyond our competence to promote the separation from the 
system of the material factors of the various forms of inflammation, of 
the living elements of malignant growths, or of the contagia of the 
infectious fevers. Neither can we, by the use of drugs taken into the 
stomach, cause the elimination or death of parasites imbedded in the 
organism, or even of such as involve the surface of the body. It is 
very different, however, with regard to the effete matters which are so 
abundantly produced in many diseases, which tend so frequently in 
them to accumulate within the blood, and which so often by their 
presence therein cause toxemic symptoms and thus add seriously to 
the dangers which the patient incurs. For this reason it is generally 
advisable to maintain, as far as possible, free action of the various 
secretory organs — of the skin, . of the kidneys, of the alimentary canal, 
and of the lungs. In febrile disorders there is not only usually a 
large over-production of urea and of matters related to urea, but the 
urine, by which alone they can be efficiently removed, is usually scanty. 



REMEDIAL TREATMENT. 



129 



It is obviously desirable, therefore, in these cases, to promote the flow 
of urine, a result which may generally be best attained by allowing the 
patient to drink freely. In gout a somewhat similar accumulation of 
effete matters, and especially of urate of soda, takes place in the blood, 
and here again consequently eliminative treatment is indicated. But 
it not unfrequently happens that poisonous matters accumulate in the 
blood in consequence of structural disease of the organs by which they 
should be separated. In disease of the kidney, urea and other effete 
nitrogenous matters are retained in the blood, in disease of the liver 
the elements of bile, in disease of the lungs carbonic acid. Under 
these circumstances unconquerable obstacles frequently exist to the 
purification of the blood. Still, good may often be effected, if not by 
promoting the eliminative action of the implicated organ, by encour- 
aging the vicarious action of other organs. In renal disease much 
benefit is generally secured by the regulated use of drastic purgatives, 
and by promoting profuse perspiration ; and in liver disease with jaun- 
dice, by encouraging diuresis. Again many substances, poisonous and 
other, which occasionally gain an entrance into the organism, tend, like 
urea and other effete matters, to be thrown off, sometimes by the kid- 
neys, sometimes by the lungs, sometimes into the parenchyma of cer- 
tain organs. Their discharge may often be hastened by appropriate 
measures. It is an important statement that lead and mercury, which 
have a tendency to be deposited in certain of the tissues, can be re- 
moved thence by means of iodide of potassium, with which they are 
said to unite in the organism, and in company with which then to 
escape with the urine. But eliminative treatment is by no means 
called for in all diseases; and, even when it is indicated, it must not 
be assumed that the emunctories must be powerfully stimulated into 
action, still less that we should act violently upon all at the same time. 
Here, as in other cases, we must be guided in our efforts by the nature 
of the case with which we have to deal, and by the phenomena which 
manifest themselves during its progress. 

5. No inconsiderable part of the duties which a medical practitioner 
is called upon to perform consists in the treatment of the secondary 
phenomena or symptoms of disease, — in relieving pain or uneasiness, in 
giving sleep, or soothing irritability or anxiety of mind, in promoting 
or checking the action of certain organs, in removing or dissipating 
matters which, from their position or quantity, interfere with the due 
performance of functions that are important to life or health. And it 
is certain that, if we do not by such measures cure the primary disease, 
we do often make life more or less tolerable, we are often successful 
in prolonging life, and not unfrequently succeed in thus prolonging it 
until the disease, which would otherwise have carried the patient off, 
itself subsides, and by its subsidence leaves him convalescent. The 
importance of relieving pain in acute inflammation of the peritoneum 
or pleura, or in enteritis, and in various forms of neuralgia, is fully 
admitted by every one. The necessity for giving sleep in traumatic 
delirium, in the wakefulness which sometimes precedes the outbreak 
of acute mania, and in many febrile and organic diseases, is equally 
recognized. The relief of spasmodic action of the voluntary muscles 

9 



130 



THE TREATMENT OF DISEASE. 



in tetanus, or of the involuntary muscles in spasmodic stricture of the 
urethra and of various other tubular organs, is often a matter of urgent 
need; as also, on the other hand, is the stimulation of an inactive 
organ, — of the heart under certain conditions, or of the flaccid uterus 
after parturition when profuse haemorrhage is taking place. The last 
examples which we shall adduce are supplied by the removal, whether 
by tapping or by medicinal means, of dropsical accumulations in serous 
cavities ; and the dissipation of effusions, or other forms of swelling, 
or of bodies which by their position compress or interfere with pas- 
sages, such as the larynx, or bowel, the patency of which is necessary 
for the maintenance of life. 

6. To obviate the tendency to death is to a considerable extent 
implied in the foregoing discussion. In a sense it is the principal 
aim of all medical treatment. The expression is, however, generally 
employed in reference to the duty which devolves upon us at the time 
when death appears to be imminent, and when the exact nature of 
the process by which death will be brought about becomes more or 
less clearly indicated. On a former page we have discussed the vari- 
ous modes of dying ; and we must refer to what is there said for the 
special indications for treatment furnished in the several cases there 
enumerated. 



PART II. 

SPECIAL PATHOLOGY. 



I.-SPECIFIC FEBRILE DISEASES. 

INTRODUCTORY REMARKS IN REFERENCE MAINLY 
TO THE INFECTIOUS FEVERS. 

Specific Origin and Spread of Epidemic and Endemic Diseases. 

The diseases to which the following remarks are intended to be 
introductory are for the most part linked together by the possession 
of certain striking characteristics. They originate severally in definite 
specific causes, they prevail endemically or epidemically, and are in 
large proportion infectious or contagious. 

They Originate in Specific Causes. — To this subject we shall pres- 
ently recur; meanwhile, the truth of the statement here made is proved 
by the fact, that the several diseases of this group never pass the one 
into the other, or (notwithstanding that they may, within certain 
limits, present variations of character) lose their specific identity — that 
while malarious poison never causes small-pox, or typhus, or scarlet 
fever, so the specific poison of either of these latter affections never 
gives origin to ague, or to any other disease than that from which it 
was derived. Small-pox produces small-pox, typhus typhus, scarlatina 
scarlatina ; and ague arises under special conditions which are produc- 
tive of ague and of ague alone. 

They Prevail Endemically or Epidemically. — The term " endemic/' 
as applied to disease, signifies the prevalence of disease among a people. 
It implies, for the most part also, its limitation within certain restricted 
areas, its dependence on local or localized causes, and a tendency to 
persist in the locality which it affects. The term " epidemic," on the 
j other hand, implies that the disease of which it is used falls as it were 
suddenly upon a people, and generally implies, further, that it spreads 
widely and rapidly, and that its prevalence is of limited duration. 
Goitre is the very type of an endemic disease, influenza perhaps the 
| most characteristically epidemic of all epidemic diseases. It is im- 
portant, however, to observe that epidemic diseases comport themselves 
! in many different ways, and that the epidemic and endemic conditions 
not unfrequently pass the one into the other. Influenza, and it may 
, be added small-pox, scarlet fever, measles, and other like affections, 



132 



SPECIFIC FEBRILE DISEASES. 



when occurring, for the first time, in an unprotected community, 
diffuse themselves generally with marvellous rapidity ; typhus and 
relapsing fever, virulent though they be, limit their spread mainly to 
those who are under certain defective sanitary conditions. Cholera, 
though distinctly epidemic, diffuses itself mainly by irregularly scat- 
tered local outbreaks— a peculiarity still more markedly belonging to 
enteric fever and to diphtheria, which, moreover, are apt to persist in 
an endemic form, in the localities into which they have been intro- 
duced. Further, many affections, which are now more or less charac- 
teristically endemic, or epidemic within restricted arese, have been, or 
are liable to become, epidemic, in the wider sense of the word, under 
certain ill-understood conditions; among these may be enumerated 
leprosy, syphilis, plague, and yellow fever. 

They are in large proportion Infectious or Contagious. — It was for- 
merly largely believed, that epidemic disease was the result of the 
operation of some mysterious influence, diffusing itself like a vapor 
over the surface of infected regions, involving equally the whole popu- 
lation, modifying the general health, tincturing the already prevalent 
diseases, and causing among those who were predisposed to it the 
specific epidemic attack. This view was formerly held with regard to 
syphilis itself — a disease which is now known, like hydrophobia and 
glanders, to be imparted only by direct inoculation. It is even now 
held by many in respect of influenza — a malady which is one of the 
most eminently contagious of maladies, and in this respect allied with 
small-pox, scarlet fever, and measles. That the origins of cholera 
and of enteric fever were long enshrouded in mystery is not surprising, 
yet even in the case of these diseases there is now scarcely room to 
doubt their diffusion by means of specific contagia. And indeed 
(though it has not yet been distinctly proved of every epidemic 
affection), the progress of pathological science leaves little room for 
doubt that all truly epidemic diseases are communicable directly or 
indirectly from the sick to the healthy, and that their spread is due 
alone to the operation of a specific virus which the former yield and 
the latter absorb. Endemic affections, on the other hand, are not 
necessarily infectious ; and some, such as ague and goitre, seem clearly 
to originate in certain poisonous matters, developed, or existing, in the 
soil of the localities which they affect. 

Behavior of Contagia within the Organism. — The virus or contagium 
of an infectious fever, having gained entrance into a susceptible body, 
remains apparently dormant in it for a time, which varies according 
to the nature of the fever, and is termed the period of latency or incu- 
bation. To this succeeds the period of invasion — the period during 
which the first symptoms of the disease manifest themselves. And on 
this, in its turn, soon supervenes the period during which the specific 
symptoms become declared. This latter, in the case of the exan- 
themata, is termed the eruptive period. In other varieties of infectious 
fevers, the period of invasion, and that which corresponds to the 
eruptive period, are for the most part indistinctly divided. In most 
cases, after the symptoms have endured for some definite period, they 



CONTAGION. 



133 



begin to abate, the period of decline or defervescence or convalescence 
ensues, and the patient is presently restored to health. 

In order to impart disease, the contagium must actually enter into 
the system. But the mode of its entrance, and the route by which it 
enters, differ in different cases. Some contagia, such as those of syphilis, 
glanders, hydrophobia, and vaccinia, can only be introduced by direct 
inoculation — the poisonous matters, which these diseases evolve, must 
be placed in substance on some delicate mucous surface, or be actually 
inserted beneath the epidermis; some are carried by the atmosphere, 
are inhaled, and enter by some portion of the respiratory mucous mem- 
brane; some are for the most part introduced with the food, and act 
primarily on the gastro-intestinal tract. Many of the diseases which 
are ordinarily conveyed by the air or by food have been found to be 
also communicable by inoculation; and it seems not improbable that 
all such diseases might, under favorable conditions, be thus imparted. 

In some of the inoculable diseases, such as syphilis and small-pox, 
a specific pimple gradually rises at the point of inoculation, specific 
affection of the lymphatic glands next above speedily ensues, and at 
or about the time when these have attained their full development 
febrile symptoms supervene, to be followed in a short time by the char- 
acteristic rash. In vaccinia the same sequence of events takes place, 
with the exception that the febrile symptoms are not succeeded by any 
specific cutaneous eruption. In these cases, the period of the develop- 
ment of the primary pimple or pock, and of the affection of the neigh- 
boring lymphatic glands, corresponds accurately to the period of incu- 
bation of natural small-pox, or of other infectious fevers not acquired 
by inoculation. It is reasonable to believe that what occurs in these 
particular affections, during the period of incubation, occurs during the 
same period, with some modifications of detail, in others; in other 
words, that specific local processes (followed by specific affection of the 
next lymphatic glands) take place in all of them, during the period of 
incubation and preliminary to the general diffusion of the poison, at 
the spot or spots at which the virus enters the organism. It is not 
improbable that the specific lesions of diphtheria, cholera, and enteric 
fever are to be regarded as the immediate consequences of the local 
action of the specific poisons of these diseases, and as corresponding 
therefore to the syphilitic chancre, or the primary pock of inoculated 
variola, and not to the eruption of the generalized disease. 

The period of general diffusion follows: the infected lymphatic glands 
shed specific elements into the blood, with which they are distributed 
throughout the organism, to sow themselves in, or to infect, those parts 
of it which offer a suitable soil for their further development or growth. 
Various constitutional phenomena, due to the effects of the poison upon 
the blood and upon the tissues, attend their diffusion ; but, in addition 
to these, various specific lesions of particular tissues ensue, which are 
more or less characteristic for each form of disease. In many cases 
(the exanthemata) a rash appears upon the skin; in some the tonsils, 
in some the salivary glands, in some the respiratory tract, in some the 
alimentary canal, in some certain other internal organs, are mainly in- 
volved. It is obvious, from the above account, that the contagious 



134 



SPECIFIC FEBRILE DISEASES. 



matters of the contagious diseases must at some time or other be con- 
tained within the blood. The blood is indeed, in some cases and under 
certain conditions, undoubtedly infectious. For the most part, how- 
ever, this fluid rapidly purifies itself of the poisonous elements which 
enter it, discharging them mainly into those organs or tissues, or at 
those surfaces, which are the seats of the specific lesions of the diseases 
to which they belong, and which become consequently surcharged with 
infectious matter. 

During the progress of a contagious disease, the contagiurn which 
gave it origin undergoes enormous development within the organism; 
an inconceivably minute quantity of the variolous poison, placed be- 
neath the skin, results in the formation of a pock, which itself contains 
an infinitely larger amount of poison than was introduced in the first 
instance, and subsequently in the formation of thousands of pocks scat- 
tered over the general surface, each one of which is as fully charged 
w T ith contagiurn as was the first. There can be no doubt that, in other 
diseases besides small-pox, this development of coutagium goes on 
during the whole period of ingravescence, beginning at the seat of its 
introduction, continuing in the lymphatics and probably in the blood, 
but taking place with especial vehemence in the cutis in exanthematic 
diseases, and in connection generally with specific lesions. 

In the majority of cases the poison, which is thus manufactured 
within the organism, is discharged from it in greater or less abundance, 
and serves to propagate the disease of which it is the specific cause. 
This discharge, which occurs mainly in connection with the seats of 
specific lesion, takes place at different periods in different diseases, and 
necessarily also from different surfaces. Thus, the contagia of cholera 
and of enteric fever are discharged with the alvine evacuations ; those 
of measles, hooping cough, and influenza escape from the respiratory 
surface; that of scarlet fever probably from the throat and skin; that 
of hydrophobia with the saliva or oral mucus; that of glanders mainly 
with the nasal secretion; and that of syphilis with the discharges from 
its specific sores. 

It is very remarkable that the majority of contagious fevers end in 
complete convalescence, that the poisonous matters which they engender 
either die out or escape from the body by one or other of the routes 
which have been enumerated. This latter process has been compared 
to the discharge of urea, or other effete matters, by the emunctories. 
But it is obviously of quite a different character; for, to take small- 
pox again as an example, there is not simply a discharge from the dis- 
eased surface of matters which had accumulated in the blood, but there 
is an actual manufacture of poison going on at each spot of disease. 
There arises, further, a remarkable condition of the organism, by which 
its susceptibility of the specific poison is destroyed; for not only does 
the poison within it die out, but the system refuses to reabsorb any of 
the abundant poison which it manufactures, and it remains for many 
years, it may be for life, free from liability to become again affected. • 

Behavior of Contagia external to the Body. — There is a time during 
which contagia exist external to the body. How do they then com- 
port themselves ? It is clear that, in this respect, they present as im- 



CONTAGION. 



135 



portant differences among themselves as they do in their influence over 
the body. The contagium of influenza is remarkable for its amazing 
diffusibility ; that of typhus clings as it were around the patient and is 
readily destroyed by atmospheric dilution ; that of scarlet fever remains 
dormant for months in articles of clothing; that of small-pox, or 
vaccinia, may be preserved for months or years between two pieces of 
glass, or concreted upon an ivory point. But the most remarkable 
peculiarities are presented by the contagia of enteric fever and cholera. 
In both cases, the specific poison is yielded by the bowel, and escapes 
with the faeces ; and in both, probably, the poison is innocuous at the 
moment of escape, and only acquires virulent properties after the lapse 
of some time — in the case of cholera, after the lapse of four or five 
days. 

Nature of Contagia. — Having briefly considered the dependence of 
epidemic diseases on specific contagia, the modes by which these 
poisons enter the body, act upon it, and finally become discharged 
from it, and indicated some of their peculiarities of behavior outside 
the body, it remains to discuss the question of the nature of contagium. 
In reference to this subject, we must not lose sight of some of the im- 
portant facts with regard to contagion which have been above adduced; 
we must bear distinctly in mind that the virus of one disease produces 
that disease only, and never any other ; that, received into the body, it 
multiplies indefinitely within it ; that it leaves the body, not by the 
organs provided for the separation of effete matters, but by a process of 
efflorescence or multiplication, taking place in certain situations and 
modes, which are characteristic for each disease; and that external to 
the body it comports itself in various manners, of which some (as in 
cholera and enteric fever) evidently imply progressive developmental 
changes. It seems impossible that these conditions can be fulfilled by 
any element, or any combination of elements unendowed w T ith life. No 
inorganic solid still less any fluid or gas, no dead organic compound, 
could thus multiply itself either within or without the body, or thus 
affect the body in its progress through it. It is impossible to conceive 
a bubble of sulphuretted hydrogen, a drop of gin, a fragment of mar- 
ble, or a grain of morphia, multiplying itself a thousandfold w T ithin 
the system, making for its discharge some special route, and leaving 
the system henceforth incapable of its further production. Nothing 
analogous to this has been shown to exist in the whole range of inor- 
ganic or organic chemistry. The facts, however, are all compatible 
with what we know of the development and behavior of organized 
beings, and especially of such as are lowest in the scale of life. We 
know how, when the spores of fungi become deposited in a suitable 
soil, they grow, and multiply, and rapidly pervade it until they have 
exhausted it ; how each fungus fructifies according to its specific char- 
acter, and yields innumerable spores which become widely diffused, 
retaining their specific characters, and their vitality (though in a 
dormant condition) under apparently the most adverse circumstances, 
until the opportunity for their development offers itself. The above, 
however, is not the only argument in favor of the dependence of infec- 
tious fevers on the development of living organisms. Others of still 



136 



SPECIFIC FEBKILE DISEASES. 



greater value remain to be adduced. 1. We know that many diseases, 
among which may be mentioned tinea tonsurans, tinea favosa, tinea 
versicolor, scabies, and those in which trichinae and hydatids are present, 
are actually the results of the presence of animal or vegetable parasites ; 
and that the behavior of the living contagia in these cases manifests at 
least as great variety as does that of the virus of the infectious fevers. 

2. The important experiments, first made by Chauveau, with regard 
to the infectious fluids of cow-pox, sheep-pox, and glanders, and since 
repeated, in the case of cow-pox, by Dr. Burdon-Sanderson, showed 
clearly that the contagious element is not uniformly diffused through- 
out those fluids, that it does not reside either in the inflammatory cor- 
puscles which they contain, or in the dissolved constituents, but in 
certain minute protoplasmic particles or living bodies, which, at the 
period of their chief infectiveness, they contain in great abundance. 

3. Specific fungous growths have actually been detected in connection 
with several of the diseases in question, under circumstances which 
leave little doubt that they are the actual contagia, or specific elements, 
of these diseases. The most important observations relate to the splenic 
fever of cattle, relapsing fever, sheep-pox, and enteric fever. In the 
first of these diseases, which is communicable by direct contagion only, 
and occasionally spreads in this way to man, peculiar vegetable organ- 
isms are universally found in the blood during the height of the disease. 
They are rod-like bodies, having a close resemblance to bacteria, and 
made up of round micrococci arranged in linear series, but not possess- 
ing the power of spontaneous motion. Free spheroids, indicating 
another stage of development of these bodies, are also found. In 
relapsing fever, another form of vegetable organisms, named spirilla, 
was detected in the blood by Dr. Obermeier, and has since been recog- 
nized by many other observers ; it is to be found only during the febrile 
paroxysms, and always disappears at the time of defervescence, and 
during the whole period intervening between the successive relapses 
of the disease. In the case of sheep-pox, recently investigated by Dr. 
Klein, at the suggestion and with the aid of Dr. Burdon-Sanderson, it 
has now been most clearly demonstrated, that a characteristic fungus 
becomes developed in the pocks which characterize the disease. This 
fungus, which seems to belong to the penicillium group, consists of a 
delicate mycelium of branching tubes, and a fructification composed of 
strings or groups of minute spores or micrococci. It appears very 
early — about the third day — in the course of the development of the 
pocks, showing itself first in the lymphatic spaces of the corium, and 
extending thence into the vesicular cavities, whose appearance in the 
corium constitutes the first stage of vesication. With the progress of 
inflammatory changes, and especially with the infiltration of the tissues 
with leucocytes, the fungus disappears, or becomes difficult of recogni- 
tion. The changes above described are found not only in the primary 
pock due to inoculation, but in the pocks of the general eruption, 
which commence on the tenth day after inoculation. It may be added 
that the living particles, before referred to as having been detected in 
vaccine vesicles, and which have been shown to be the infective ele- 
ment of this affection, have been described by an eminent botanist 



GENERAL RULES OF MANAGEMENT. 



137 



(Cohn) as vegetable organisms, under the name of Microsphcera vac- 
cinia?, ; he shows that they may exist singly or in couples, or in beaded 
threads, and that their chemical reactions are those of micrococci. It 
may be further added, that Dr. Weigert, by the careful microscopical 
examination of the skin of patients dead of small-pox, had, previous to 
Cohn's observations, discovered in the lymphatics of the cutis, in rela- 
tion with the pustules, an accumulation of granular matter, which 
exhibited all the characters of micrococci. It is obvious, then, that 
j there are strong reasons for concluding that the same relations subsist 
between the development of the vaccine and variolous pocks and the de- 
velopment of specific forms of fungus as have been conclusively shown 
to subsist between these processes in the case of sheep-pox. More re- 
| cently, Dr. Klein has been engaged in examining the intestines in cases 
i of enteric fever, and he has ascertained that, in this disease also, a special 
! form of fungus is connected with the specific lesions of Peyer's patches 
and of the solitary glands. This is characterized by a distinct mycelial 
growth, by greenish spherical formations, two or three times as large as 
blood -corpuscles, and by micrococci or spores of extreme minuteness, 
which occur singly or in couples, or in strings, or in irregular clusters. 
The fungus exists on the surface of the mucous membrane and within the 
tubular glands, but it pervades the epithelium, and becomes especially 
abundant in the lymphatic spaces and channels, and in the small veins. 
The arguments in favor of the dependence of the specific contagious 
| diseases on living organisms, apart even from the remarkable series of 
observations which have just been adduced, seem almost conclusive. 
It might still, however, have remained a question whether these living 
organisms were animalcules, as some have supposed, vegetables as others 
believe, or particles of the living organism of the patient, as Dr. Beale 
thinks, endowed with specific properties. It need scarcely be said, 
that these recent observations go far to give a positive solution to this 
question, and at the same time to confirm the belief of those who main- 
tain that the specific fevers, in other words, their specific causes, never 
originate spontaneously. If contagia be vegetable parasites, it becomes 
especially easy to understand the numerous differences of behavior which 
characterize them, and their apparent development de novo under various 
combinations of circumstances. 

General Rules to be Observed in the Management of Epidemic or 
Contagious Diseases. 

We can, as a rule, do little or nothing medicinally for the direct 
i cure of the infectious fevers. So far as the patient is concerned, we 
! can only treat symptoms as they arise, support his strength by appro- 
j priate nourishment, promote the action of the secretory organs, and 
take precautions against the supervention of complications. It be- 
comes, however, a most important duty of the medical man to prevent 
I the spread of these diseases. The measures to be adopted for this end 
will differ to some extent, according to the character of the disease he 
has to deal with, and according to the properties and peculiarities of 
' the contagiuin on which it depends. The following general rules, 



138 



SPECIFIC FEBRILE DISEASES. 



partly derived from " Suggestions by the Society of Medical Officers 
of Health," partly from other sources, may be laid down as generally 
applicable : 

1. The patient should be at once separated, as efficiently as circum- 
stances permit, from the other inmates of the house, and if possible 
placed in a top room, and have that floor devoted to him and his 
attendant. 

2. All bed-curtains and other hangings and carpets, and all articles 
of dress and the like in wardrobes and cupboards, and all unnecessary 
articles of furniture, should be removed thence. 

3. The room should be well ventilated ; windows should be kept 
partly open, communication with the chimney free, and if the weather 
or size of the room permit, the fire burning. The floor should be 
sprinkled daily with disinfectant fluid and cleansed. 

4. The door should be kept closed, and a sheet hung outside it so as 
to cover every crevice, and kept wet with a solution of carbolic acid, 
chloride of lime, or Concly's fluid. 

5. Everything that passes from the patient (spit, vomit, urine, faeces) 
should be received into vessels containing either of the above solu- 
tions ; and an additional quantity of solution should be added to the 
vessel, before removing it from the room and emptying it into the 
closet. All superabundant food or drink, and all scraps, should be 
similarly treated, and under no circumstances partaken of by other 
persons. 

6. Pieces of rag should be used for wiping discharge from the nose 
or mouth, and burnt immediately after use. 

7. All cups, glasses, spoons, and such-like articles, used in the sick- 
room, should be placed in some disinfectant solution before leaving it, 
and subsequently washed in hot water. 

8. All bed and body linen should at once, and before leaving the 
room, be put into a disinfectant solution, and after remaining in it for 
at least an hour, boiled in water. 

9. The patient's person and bed should be kept scrupulously clean ; 
and when, during the progress of his disease, scales or crusts form upon 
the skin, their diffusion should be prevented by smearing the surface 
daily with oil. 

10. Nurses in attendance should if possible be such as have already 
had their patient's disease ; their dresses should be of cotton or of some 
other washable material; they should keep their hands clean, using 
carbolic acid soap, or adding Condy's fluid to the water in which they 
wash, and should avoid as far as possible inhaling the patient's breath, 
or other emanations from his person or from his discharges. They 
should remain with the patient; or if compelled to leave the room, 
leave it under proper precautions; and under no circumstances mix 
with other members of the household. 

11. No visitors should be allowed, or if allowed, should conform, 
as closely as circumstances permit, to the conditions required of the 
ordinary attendant. 

12. The medical attendant should remain no longer than necessary 
in the sick-room, and expose himself as little as possible to contamina- 



GENERAL RULES OF MANAGEMENT. 



139 



tion; should wash his hands before leaving, hold as little subsequent 
communication as possible with the inmates of the house, and never 
go direct, or without proper precautions, from the infectious to other 
patients. 

13. The patient must not be allowed to mix with the rest of his 
family, until all peeling of the skin has ceased, or until all specific 
phenomena of disease have disappeared, and until he has been well 
purified by the use of warm baths and carbolic acid soap or Condy's 
fluid. Clothes used during the time of illness, or in any way exposed 
to infection, must not be worn again until they have been properly 
disinfected. 

14. When the sickness has terminated, the sick-room and its con- 
tents should be disinfected and cleansed. This should be done in the 
following manner : Spread out, and hang upon lines all articles of 
clothing or bedding ; well close the fire-place, windows, and all open- 
ings; then take from a quarter to half a pound of brimstone, broken 
into small pieces; put it into an iron dish, supported over a pail of 
water, and set fire to it by putting some live coals upon it ; then close 
the door, stopping all crevices, and allow the room to remain shut up 
for twenty-four hours. At the end of this time the room should be 
freely ventilated by opening doors, windows, and fire-place, the ceiling 
whitewashed, the paper stripped from the walls and burnt, and the 
furniture and all wood and painted work washed with soap and water 
containing a little chloride of lime. Beds, mattresses, and other articles 
which cannot well be washed, should, if possible, be submitted to a heat 
of from 210 to 250 degrees for two hours or more, in a disinfecting 
chamber. 

15. The house in which the patient, suffering from infectious dis- 
ease, resides should, during his illness, be well ventilated and kept very 
clean ; all sinks and water-closets should be in good order, and have 
solution of sulphate of iron, of carbolic acid, or of chloride of lime, 
poured into them daily; dust-bins should be regularly emptied, all 
offensive accumulations removed or disinfected by the free use of 
chloride of lime ; and all water-butts and cisterns kept clean and well 
covered. Indeed, the greatest possible care should be taken to pre- 
vent any kind of contamination of drinking-water. 

For the purposes of artificial disinfection, many different substances 
may be employed. The following are among the more commonly use- 
ful: Sulphate of iron, one pound to the gallon of water; chloride of 
lime, one pound to the gallon ; carbolic acid (No. 4), a quarter of a pint 
to the gallon ; Condy's red fluid diluted with fifty times its bulk of 
water; the green fluid with thirty times its bulk of water. Chloride 
of lime, carbolic acid, and Condy's fluid are, on the whole, preferable 
for disinfection in connection with the infectious fevers. For the dis- 
infection of linen and other wearing apparel, chloride of lime should 
be avoided on account of its corrosive quality. Solution of carbolic 
acid, or of Condy's fluid, is preferable. 



140 



SPECIFIC FEBRILE DISEASES. 



INFLUENZA {Epidemic Catarrh). 

Definition. — A contagious, catarrhal affection of the respiratory tract, 
of short duration, but attended with much prostration, and occurring, 
for the most part, in widespread epidemics. 

Causation and History. — Influenza is one of the most mysterious, 
and at the same time one of the most interesting, diseases with which 
we are acquainted. The obscurity of its origin; the swiftness with 
which it spreads throughout a district into which it has been intro- 
duced, passes from one city to another city, from one country to another 
country, thus involving entire continents within very brief limits of 
time ; the shortness of its visitation in any locality — its stay rarely ex- 
ceeding six weeks or two months ; the suddenness and completeness of 
it? disappearance; and the irregularity of its epidemic visitations: all 
combine to render it the most typical of all epidemic affections. Its 
origin and diffusion have, therefore, not unnaturally been sought for 
in some occult telluric, atmospheric, or electrical condition, some wide- 
spread morbific influence external to, and independent of, the frames 
which it affects injuriously. On the other hand, experience has shown 
that its prevalence is altogether independent of climate and of season, 
and has no relation with defective drainage or other local sources of 
sanitary evils. Further, it is quite certain that it is infectious in a 
very high degree — that its conveyance has been frequently traced from 
locality to locality by the direct agency of those who are suffering from 
it, and its diffusion in fresh localities from these infected immigrants 
as centres. It is certain, therefore, that the disease may be imparted 
by a contagium, which, like other contagia, is specific, multiplies in- 
definitely in the body into which it has gained an entrance, and is 
thence evolved in marvellous abundance. Under these circumstances 
it seems most philosophical, at all events most consonant with the 
present state of our knowledge, to reject the vague theories first adverted 
to, and to assume (notwithstanding many difficulties) that the conta- 
gious influence, which certainly causes it to spread in large numbers 
of cases from man to man, affords the true explanation of its epidemic 
diffusion. The virus is doubtless given off with the breath. The 
disease has never been imparted by inoculation ; its attacks are in no 
degree determined by age or sex; and it is quite uncertain whether, or 
to what degree, one attack is protective for the future. It has been 
held by some that epidemics of influenza have a tendency to precede, 
or to follow, or to be associated with other epidemic diseases, such as 
cholera. This relation, however, is doubtless quite accidental. 

Symptoms and Progress. — The duration of the latent period of influ- 
enza has not been accurately ascertained. According to Dr. Squire it 
is very short, namely, three or four days, or at the outside a week. Its 
invasion is for the most part sudden, and marked by elevation of tem- 
perature ; by more or less severe chills, especially along the spine, 
sometimes amounting to rigors, and alternating with flushes of heat; 
by pain, or uneasiness, or a sensation of burning in the back and limbs ; 
and sometimes by vomiting. With these symptoms are occasionally 



INFLUENZA. 



141 



associated from the beginning, but more commonly after the lapse of 
some hours, severe catarrhal symptoms, indicated by dryness, redness, 
and swelling of the mucous membrane of the nose, sneezing, and, in 
consequence of involvement of the frontal sinuses, intense frontal head- 
ache; by more or less affection of the conjunctivae and pain in the eye- 
balls ; by inflammation of the fauces, larynx, trachea, and bronchial 
tubes to their smallest ramifications, soreness of throat, hoarseness, con- 
stant hacking, often croupy, cough, rapidity and difficulty of breathing, 
and a sense of tightness or constriction of the chest. The skin at this 
time is generally dry, the tongue covered with a moist fur, the appetite 
lost, the pulse quickened and moderately full, the bowels confined, the 
urine febrile; and, above all, there is extreme prostration, with mus- 
cular weakness, much depression of spirits, and prsecordial oppression. 
In the subsequent progress of the disease, general prostration, and in- 
flammation of the bronchial tubes, constitute its most striking features. 
The heat of skin now probably subsides somewhat ; but the patient is 
still apt to have alternate chills and flushes ; the fever assumes a remit- 
tent character; perspirations, sometimes very copious, break out; su- 
damina not unfrequently appear, and occasionally an herpetic eruption 
about the lips ; and the mucous membrane of the nose and respiratory 
passages begins to secrete a more or less abundant, thin, colorless mucus, 
which before long assumes a muco-purulent character. The soreness 
of the throat and hoarseness probably continue ; the difficulty of breath- 
ing and the cough increase; and on auscultation the breath-sounds are 
found to be feeble, or masked by sibilant and sonorous rhonchi and 
subcrepitation ; the face gets congested or livid ; the pulse increases 
in rapidity, and loses in fulness and strength ; the tongue becomes more 
thickly coated, except perhaps at the tip and edges, and sometimes dry 
and brown ; the sickness possibly continues, and diarrhoea may come 
on ; debility grows extreme, and muscular tremors and subsultus may 
appear; the intelligence becomes markedly dull and impaired, and 
delirium is apt to supervene. Epistaxis is of common occurrence, and 
otitis and jaundice are neither of them infrequent. 

In mild cases, the disease is at its height on the second or third day, 
and then begins to decline gradually; in more severe cases, however — 
cases in which there is much pulmonary affection — convalescence does 
not commence until as late as the tenth or twelfth day. The patient 
is always much reduced in strength at this time ; and convalescence is 
protracted in consequence partly of persistent debility, partly of the 
continuance of catarrhal affections, or of a proclivity to catch cold. 

The most important of the complications of influenza are those arising 
out of the characteristic lesions of the air-passages: namely, laryngeal 
inflammation, bronchitis (especially bronchitis of the smaller tubes), 
and lobular and lobar pneumonia, often associated with pleurisy. These 
conditions creep on insidiously, during the progress of the case, and 
reveal themselves only by an aggravation of the ordinary symptoms, 
or by the blending of their proper symptoms with those due to the 
influenza itself. Gastro-intestinal complications are also described ; 
but there is no doubt that the accidental concurrence, which is so com- 
mon, of influenza with other diseases, explains a large proportion of 



SPECIFIC FEBRILE DISEASES. 



the cases in which it is found associated with these gastrointestinal, 
and other less frequent, forms of complication. 

Single cases of influenza may readily be confounded with severe 
catarrhal affections of the nose, throat, and bronchial tubes. The high 
fever, however, the extreme prostration, and the short duration of the 
graver symptoms, are, all, important characteristics pointing to the 
specific nature of the disease. If to these peculiarities be added the 
fact of epidemic prevalence mistake becomes no longer possible. 

The percentage of deaths from influenza is very small, and indeed 
the uncomplicated disease is very rarely fatal. Still, it attacks so large 
a proportion of a population (in somes cases between a quarter and a 
half of the total number), that that small percentage does very largely 
augment the mortuary rate. Indeed, the prevalence of influenza has 
been found to augment the death-rate much more highly than the 
prevalence of cholera. The disease is chiefly fatal among the very old, 
and such as are already suffering from pulmonary or cardiac affections. 

Morbid Anatomy. — There is nothing distinctive in the morbid 
anatomy of influenza. Patients chiefly die of pulmonary mischief ; and 
then the evidences of this may be detected in the form of inflammation 
of the bronchial membrane, secretion into the tubes, emphysema or 
collapse of tissue, or both, or pneumonia, combined or not with pleurisy. 

Treatment. — In treating influenza, it is important to adopt the 
hygienic measures which are generally useful in the treatment of in- 
fectious febrile affections. Medicinal treatment is not generally very 
efficacious ; small doses of nitre alone, or combined with a few drops 
of laudanum, have been highly recommended. But probably nothing 
is better than a few drops of ipecacuanha wine combined with a little 
laudanum, or ammonia associated with solution of acetate of ammonia, 
administered every two or three hours. If the bowels are confined, 
they may be moved either by mild aperients or by enemata. The 
inhalation of steam may relieve the laryngeal and bronchial affection, 
as also may the diffusion of moisture through the atmosphere of the 
room. The removal of blood, even by leeches, is rarely admissible; 
still, in cases in which the congestion of the lungs is extreme, and 
death by asphyxia impending, they may be justifiably employed. 
Blisters again are of doubtful efficacy. Flannel or cotton-wool, bran 
poultices or hot, fomentations to the chest are, on the other hand, often 
beneficial, as also are mustard plasters. But little food will be taken 
probably, or is needed, during the earlier days of the disease ; and such 
as is allowed should consist mainly or exclusively of milk, and the 
various farinacea suspended or dissolved in milk or water. Thirst 
may be relieved by these means, or by the administration of water, tea, 
lemonade, soda water, or other such drinks. Owing to the remarkable 
prostration which is generally present, stimulants are for the most part 
soon required. The nature of the stimulants to be employed must 
depend on circumstances. When the patient begins to amend, tonics 
are indicated, and the diet must be gradually modified, until it com- 
bines the ordinary proportions of solid and fluid, and of animal and 
vegetable matters, which constitute the diet of healthy persons. The 
presence of complications will necessarily, in many cases, make some 



HOOPING-COUGH. 



143 



modification of treatment desirable. It need only be said, however, 
in reference to this point, that, as in the uncomplicated disease, so 
here, depletory measures are generally attended with risk, and very 
rarely called for. 



HOOPING-COUGH. (Pertussis.) 

Definition. — An infectious disorder, for the most part of long dura- 
j tion, characterized by inflammation of the respiratory tract and a 
peculiar paroxysmal cough. 

Causation. — Hooping-cough is an affection which is met with both 
sporadically and in an epidemic form, attacking children mainly, but 
not altogether sparing adults or persons of advanced age. It is said to 
be more common in spring and autumn than in other seasons ; it is 
probably, however, not more common at these times, but attended 
then with a specially high mortality. Neither climate, nor other 
hygienic conditions, have any special influence in promoting its spread ; 
epidemics of it are, however, frequently associated with epidemics of 
scarlet fever or measles ; and it is held by many that there is some kind 
of mysterious relation or attraction between them. There is no doubt 
that it is contagious in a very high degree, especially during the earlier 
I period of the disease; that its contagium is mainly conveyed through 
the atmosphere, though partly by fomites, and is given off with the 
breath. One attack confers almost complete immunity against subse- 
quent attacks. 

Symptoms and Progress. — As in all similar diseases, a period of 
latency intervenes between the inception of the virus and the occur- 
rence of symptoms. The duration of this period has not been 
accurately ascertained. It is probably about a fortnight. 

The invasion of hooping-cough closely resembles that of an ordinary 
catarrh, and is often undistinguishable from it. There is more or less 
fever, with irritability or inflammation of the mucous membrane of the 
respiratory tract, and frequent cough, attended with much tickling in 
| the throat and some expectoration of mucus. Some sonorous rhonchus 
may be detected on listening to the chest, but in other respects the 
I respiratory sounds are healthy. There may be injection of the con- 
' junctivse, photophobia, and nasal catarrh with sneezing. The main 
points in which it differs thus early from ordinary catarrh are, that the 
I fever is commonly higher ; the cough much more troublesome, occur- 
j ring sometimes incessantly, night and day, several times in the minute; 
, and these symptoms all much more persistent, lasting often for a week 
i or fortnight without presenting any material change. 
I About the end of this time the symptoms become modified; the 
| fever abates, and probably soon disappears, and gradually the irritative 
| cough of the period of invasion subsides, to be replaced more or less 
completely by the peculiar paroxysmal cough which characterizes the 
disease. Single paroxysms of this cough may be almost exactly simu- 
. lated, in children especially, by the effects of the application of pepper, 



144 



SPECIFIC FEBRILE DISEASES. 



or other irritants, to the laryngeal mucous membrane. But in its 
best-developed form, and by its recurrence, it is quite pathognomonic. 
The paroxysm is preceded by tickling in the throat, and perhaps pain 
beneath the sternum ; and at the same time a little rhonchus is probably 
audible on applying the ear to the chest. The child seems to know 
what is impending, becomes quiet and anxious, and for a short time 
seems to struggle against it. If lying down it rises to the sitting or 
standing posture, and when up, clutches any firm object which is near, 
or rushes to its nurse or mother. The actual attack begins usually 
with a deep inspiration. This is at once followed by a rapid succes- 
sion of short coughs, with no intervening inspirations, which, gradually 
becoming feebler and feebler, are continued until the chest is almost 
empty of air, the veins of the head and neck turgid, the face congested 
and livid, the eyes watery and starting from the head, the whole sur- 
face bathed in perspiration, and asphyxia becomes imminent. Then 
succeeds a long, whistling, crowing, or whooping inspiration, which is 
prolonged until the chest is once more distended with air. But the 
patient is not yet relieved, for the cough immediately recurs, and may 
be repeated two or three times in continuous succession until the child 
is completely exhausted. During the paroxysms, which often last for 
two or three minutes, and more especially at their close, a considerable 
quantity of viscid transparent mucus is discharged, and very often the 
contents of the stomach are vomited. In the attack the child may 
faint or become insensible ; the urine and even the faeces may be voided ; 
punctiform extravasations of blood may occur beneath the conjunctiva?, 
in the skin of the eyelids and other parts of the face ; and there may 
be hemorrhage from the nose, and occasionally even from the air- 
passages and from the ears. The membranse tympani have occasionally 
been ruptured. The attacks do not invariably begin in the manner 
above described ; for occasionally the paroxysmal cough precedes the 
long-drawn noisy inspiration ; and occasionally complete spasmodic 
closure of the glottis, followed perhaps by insensibility, replaces the 
normal paroxysm. After the paroxysm is over, the child remains 
more or less exhausted for a time ; but for the most part soon resumes 
his amusements, and appears to have little or nothing the matter with 
him. The paroxysms recur at irregular intervals, and vary in number 
from twenty to two hundred (according to the severity of the case) in 
the course of the day and night, but are almost always more numerous, 
as well as more severe, at night time. In the interparoxysmal period, 
auscultation of the chest reveals only slight indications of catarrh ; but 
when the patient is making the crowing inspiration no sounds whatever 
are audible within the chest. 

After the above symptoms have lasted with little change for several 
weeks (from three or four to eight or ten usually), the period of con- 
valescence commences. This is of very various duration, and is espe- 
cially apt to be prolonged if the weather be inclement, if the patient be 
neglected, or if complications have supervened. During its continuance, 
the attacks of cough gradually decrease in number and severity, and 
lose their paroxysmal character ; the expectoration becomes thicker and 



HOOPING-COUGH. 



145 



opaque, and then ceases ; and the patient more or less rapidly regains 
| health and strength. 

Attacks of hooping-cough vary very much in their severity and 
duration; and just as scarlet fever, or measles, may occur without the 
development of its characteristic rash, so hooping-cough may pass 
through all its stages and yet its cough be never attended with the 
characteristic whoop. This is especially the case in attacks of excep- 
tional mildness, or when it affects the adult. Trousseau records a case 
j in which an attack of hooping-cough lasted three days only. Its en- 
tire duration may certainly be as short as a week or two ; but much 
more frequently ranges between six and twelve weeks. Occasionally 
the disease does not wholly disappear for six, or even twelve, months, 
j If, in the fully developed disease, the paroxysms of cough do not 
j exceed twenty in the four-and-twenty hours, the case may be regarded 
as a mild one. If they exceed forty or fifty, the case is certainly 
severe; and the child is probably ill and feverish, and has signs of 
pulmonary congestion or bronchitis in the intervals between them. If 
they are still more numerous, the danger of complications, and to life, 
is serious. Hooping-cough (although one of the most common causes 
of death in children) is, however, rarely fatal in the absence of compli- 
cations. These are apt to come on in the second period of the disease, 
and especially in cases of unusual severity. They are mainly vomit- 
ing, bronchial inflammation, pulmonary collapse, lobular pneumonia, 
! and emphysema, together with epileptiform convulsions and other 
forms of head-mischief. Vomiting chiefly attends the paroxysms of 
cough, and if these be frequent, innutrition, emaciation, and debility 
will necessarily result. The pulmonary complications reveal them- 
selves by difficulty of breathing, lividity of face, crepitation and sibilant 
! rhonchus (without any necessary dulness on percussion of the chest), 
increased frequency of pulse, and rapid impairment of strength. The 
emphysema of the lungs, which is the result of laceration of the air- 
i cells, is in children often interlobular, and occasionally spreads through 
; the root of the lung to the connective tissue of the neck, face, and 
chest. Convulsions occur, chiefly in infants who are teething, and may 
be due either to reflex action only, or to the congestion of the brain 
which attends the paroxysm of cough — in other words, they may be 
either ordinary attacks of eclampsia, or attacks resembling those of 
laryngismus stridulus, respiration being arrested by spasmodic closure 
of the glottis, and insensibility supervening, attended with convulsive 
movements of the muscles of the face and eyes. These complications 
are, no doubt, serious, and the latter especially may be suddenly fatal, 
i yet the great majority of children who experience them recover per- 
I fectly. Dr. E. Smith has shown that hooping-cough is the most fatal 
j of all the diseases of children under one year of age, that sixty-eight 
] per cent, of all the deaths from it occur under two years of age, and 
j only six per cent, above the age of five years. 

Morbid Anatomy. — The lesions observed after death from hooping- 
; cough are always those of its complications : namely, congestion of the 
mucous membrane of the larynx and other air-passages, with secretion 
' into the bronchial tubes, collapse of lung-tissue in patches, lobular pneu- 

10 



146 



SPECIFIC FEBRILE DISEASES. 



monia, emphysema, and in children interlobular emphysema. Post- 
mortem examination indeed throws no light whatever on the nature of 
the disease. Congestions of the medulla oblongata, and of the pneu- 
mogastric nerves, which have been described as occurring in hooping- 
cough, are probably purely accidental conditions, if not the result of 
mere post-mortem changes. So again, enlargement of the bronchial 
glands, which has been frequently observed, has no necessary connec- 
tion with it. It has been much discussed, whether the disease is essen- 
tially nervous, or a mere inflammatory condition of the respiratory 
mucous membrane. It seems probable, however, that it is not exactly 
either one or the other ; but that it is, like other infectious fevers, the 
result of a virus, which affects more or less the whole system, but has 
a special tendency to involve the respiratory mucous membrane, pro- 
ducing in it a slight but specific inflammatory change, to the effect of 
which on the peripheral ends of the pneumogastric nerves the cough, 
with its peculiar characteristics, is due. This view is confirmed by the 
fact, that it is evidently from the implicated mucous surface, that the 
contagium of the disease is chiefly, if not exclusively, emitted. 

Treatment. — As is the case with all diseases of uncertain duration 
and of intractability, many specifics have been vaunted for the success- 
ful treatment of hooping-cough. Among the more important of these 
are hydrocyanic acid and belladonna. With respect to the latter 
remedy, Trousseau strongly urges that it should be given in one dose 
daily — and that in the morning on an empty stomach; and that, if an 
increase be necessary, it should be by augmentation of the morning's 
dose. For infants under four he recommends, to begin with, a pill 
made with y 1 ^ gr. of the extract and t 'q gr. of the powdered leaves, or 
•too g r - °f the neutral sulphate of atropia. If hydrocyanic acid be 
preferred, from one to two minims of the dilute preparation may 
(according to Dr. Roe) be given to young children every three or four 
hours. Strychnia, hyoscyamus, conium, arsenic, iron, bromide of potas- 
sium and bromide of ammonium, have also been strongly recom- 
mended, as also have alum, tannin, and the mineral acids. It is 
almost certain, however, that no drug has any direct influence over 
the course of the disease; and that hence our efforts must be directed to 
the relief of distressing symptoms, to the prevention of complications, 
and to the maintenance of the patient's strength. To these ends, it is 
important that he be kept to his room, which, though well ventilated, 
should be maintained of uniform temperature; that, if not confined 
to bed, he be clothed in flannel ; and, generally, that he be not exposed 
to draughts, or conditions liable to cause pulmonary inflammation. 
For medicine, there is probably nothing better than a combination of 
a few drops of ipecacuanha wine with a minute proportion of laudanum 
or belladonna, to be administered every two, three, or four hours. 
Counter-irritants are sometimes useful ; and the application of a strong 
solution of nitrate of silver to the larynx has been much recommended, 
especially by Bouchut and Watson. The patient's diet must be regu- 
lated according to circumstances; but generally it should be plain, 
wholesome, and nutritious. In the period of convalescence, tonics and 
change of air, or, failing this, daily exercise in the open air are advisa- 



MUMPS. 



147 



ble. When complications arise they must of course be treated specially. 
But they need no treatment distinct from that of the same affections 
occurring under other circumstances. 



MUMPS. (Parotitis.) 

Definition. — A contagious fever, of which the chief characteristic 
phenomenon is inflammation of the salivary glands. 

Causation. — Mumps, like scarlet fever, measles, and hooping-cough, 
is a malady which is generally present among us, in a greater or less 
degree, and every now and then assumes an epidemic character. Like 
them, moreover, it is extremely infectious, infects, as a rule, but once 
in a lifetime, and may be regarded as mainly a disease of childhood. 
It is not, however, confined to childhood ; and unprotected adults, and 
persons even of advanced age, may suffer from it. It is probably not 
influenced by sex ; and there is no reason to believe that its prevalence 
depends, in any degree, on season, weather, or climate. The virus of 
mumps seems to be contained principally, if not solely, in the breath. 

Symptoms and Progress. — The incubative period of mumps doubt- 
less varies ; many cases, however, have been recorded in which it seems 
to have been fourteen days ; and this may probably be taken as its 
average duration. The invasion of the disease is sometimes indicated 
by febrile symptoms and headache, on which, after a few hours or a 
day or two, parotid inflammation supervenes ; but, in many cases, the 
affection of the parotid gland precedes the febrile phenomena, or accom- 
panies them from the first. In these latter cases, the patient first com- 
plains of aching and tenderness behind one of the ascending rami of 
the lower jaw; and, in a short time, a little fulness is perceived there, 
completely obliterating the groove normally existing in that situation. 
The aching, and tenderness, and swelling gradually increase for three 
or four days, until the whole of the parotid region is occupied by a 
.dense elastic tumor, which extends forwards over the masseter muscle, 
and downwards below the angle of the jaw, and over which the skin 
may assume a rosy hue. Sometimes, the inflammation remains limited 
to one parotid gland ; but more frequently, it involves both parotids, 
and both submaxillary glands as well, attacking them successively at 
short intervals, so that all become involved in the course of two or 
three days. The inflammation spreads also to surrounding parts, and 
especially to the fauces and the tonsils. When the affection embraces 
all the glands, and is fully developed, the swelling (which then in- 
volves the paro^tidean and inferior maxillary regions of both sides) 
marvellously alters the character of the face, giving to its sides great 
fulness and breadth, and adding beneath a large double chin. The 
glandular affection generally reaches its full development in from three 
to six days, and remains stationary for a day or two longer. During 
the whole of this period the swollen parts are firm and tense, very 
tender on pressure, and attended with much aching, which becomes 



148 



SPECIFIC FEBRILE DISEASES. 



exceedingly severe when the jaw is moved, and even when the act of 
deglutition is performed. Hence the patient cannot masticate, and has 
much difficulty in swallowing, and the saliva tends consequently to 
accumulate in his mouth. The febrile symptoms moreover continue — 
the temperature sometimes attaining a height of 103° or 104°; and 
there is more or less thirst and anorexia. The character of the saliva, 
and its quantity, are not usually altered, at all events not altered ma- 
terially. After a time, which varies according to the severity of the 
case, and rarely exceeds a week, the swelling of the glands begins to 
subside, and therewith all the general symptoms. The whole duration 
of the illness may be a week, but is more frequently ten or twelve days 
or a fortnight; but even at the end of that time, the shrunken sub- 
maxillary glands may often still be felt of almost stony hardness. 
Occasionlly the skin over the swollen regions desquamates. 

It sometimes happens in the course of mumps (generally in the 
period of its decline, and occasionally after it has apparently disap- 
peared), that in the male one or both of the testicles become enlarged 
and painful, and in the female inflammatory swelling of the mammae 
or labia comes on. These complications supervene generally without 
warning, but at times are preceded by apparently unaccountable symp- 
toms of the most alarming kind — sometimes severe collapse, sometimes 
high fever with delirium. They subside in the course of a few days. 
Atrophy of the testicle occasionally follows. 

Mumps is a disease of little gravity, and rarely, if ever, terminates 
in death. It is apt, however, to leave behind it a good deal of feeble- 
ness of health. It is most likely to be confounded with non-specific 
inflammation of the parotid, and inflammatory enlargement of the 
cervical lymphatic glands ; but, under any circumstances, the confusion 
can be only temporary 

Morbid Anatomy. — So little opportunity is afforded of investigating 
the morbid anatomy of mumps that little can be said positively on the 
subject. The salivary-gland inflammation probably differs anatomi- 
cally in no respect from that arising from other causes, but it never 
proceeds to suppuration. There is doubtless considerable infiltration 
of the connective tissue of the glands ; and indeed the infiltration ex- 
tends beyond the limits of these organs, involving more or less of the 
subcutaneous connective tissue on the one hand, and of that of the fauces 
on the other. 

Treatment. — Persons suffering from mumps should be kept out of 
draughts, and, if not confined to the bed or sofa, at least debarred from 
making active exertion. The swollen parts may be relieved by fomen- 
tations, or the application of flannel or cotton-wool. The bowels may 
be kept slightly open. The patient should be fed, during the ingra- 
vescence of the disease, on milk, bread and milk, eggaj and other like 
foods, which need no mastication. When alarming symptoms show 
themselves, ammonia and other stimulants are indicated. 



MEASLES. 



149 



MEASLES. {Rubeola. Morbilli.) 

Definition. — A contagious exanthem, characterized by the presence 
of catarrh of the respiratory mucous membrane, and a peculiar erup- 
tion, coming out on the fourth day. The disease usually lasts between 
one and two weeks. 

Causation. — Measles is one of the most virulently contagious of dis- 
eases ; and, although its contagium can probably not be so long pre- 
served in an active form by fomites, or in other ways, as can the con- 
tagia of scarlet fever and small-pox, the presence of a case of measles 
amongst a number of unprotected persons will, as a rule, induce a more 
speedy, a more certain, and a more widespread outbreak of the disease 
than would under similar circumstances be induced by either of the 
other exanthems. This peculiarity is due, in some measure, to the fact 
that the contagiousness of this disease is fully developed at a. very early 
stage, being indeed at its height on the second, if not the first, day of 
invasion, when the specific nature of the attack is not yet revealed — a 
fact which explains also the great difficulty, if not the impossibility, of 
effectually preventing its spread in households and in schools. Measles 
is generally present in a sporadic form, but at irregular intervals as- 
sumes an epidemic character, spreading rapidly amongst those who 
have not.yet suffered from it, and subsiding when its pabulum becomes 
exhausted. It is mainly a disease of childhood ; not, however, so much 
because adults are naturally indisposed to take it, as because, from the 
constant presence of the disease amongst us and its extreme contagious- 
ness, almost all persons are attacked with it early in life, and are thus 
protected from subsequent attacks. In exceptional cases, second and 
even third attacks take place in the same individual ; and occasionally 
the second attack follows so quickly on the first that it constitutes a 
relapse. This proclivity to repeated attacks occasionally runs in fam- 
ilies. In the great majority of cases, however, one attack is perma- 
nently protective. 

Symptoms and Progress. — The latent period of measles varies like 
that of all other similar diseases ; its extreme limits are probably seven 
and twenty-one days. When the disease has been given by inocula- 
tion of the nasal mucus, the first symptoms are said to have manifested 
themselves on the seventh or eighth day. But when it is caught, in 
the usual way, by inhalation of the virus, the incubative period is 
generally from twelve to fourteen days. 

During this period the patient is, with rare exceptions, apparently 
in good health ; but occasionally he suffers from lassitude, debility, and 
slight febrile disturbance. The invasion of the disease is marked by 
catarrhal symptoms, in association with slight fever. There are chills 
or slight rigors, with elevation of temperature and acceleration of pulse ; 
and, at the same time, the mucous membrane of the nose becomes in- 
jected and irritable, and secretes a thin mucus, and there is frequent 
sneezing and sometimes epistaxis. The catarrhal affection speedily ex- 
tends to the frontal sinuses, causing frontal headache; to the eyes, 
causing congestion of the conjunctivae, watering, and some intolerance 



150 



SPECIFIC FEBRILE DISEASES. 



of light ; to the fauces and mouth, inducing patchy redness; and to the 
larynx, trachea, and bronchial tubes, causing soreness, hoarseness, and 
a slight hacking cough. Occasionally in children the disease is ushered 
in with an epileptiform convulsion, or several such convulsions ; and, 
on the other hand, not unfrequently the initiatory symptoms are so 
slight as to escape observation. During the period of invasion, the 
skin is generally dry, although sweats, as a rule, supervene on the 
rigors ; the tongue remains natural or becomes somewhat furred ; there 
is loss of appetite, sometimes sickness and thirst, swimming in the head, 
and occasionally on the third day some remission of symptoms. 

On the fourth day (inclusive) after invasion, sometimes a little earlier, 
sometimes later, the catarrhal symptoms and the fever become aggra- 
vated, the temperature rises, the pulse quickens, the patient becomes 
dull and perhaps a little confused, diarrhoea sometimes comes on, and 
the characteristic eruption begins to appear. This first shows itself on 
the forehead and temples, near their junction with the hairy scalp, on 
the cheeks, chin, and back of the neck, whence it gradually diffuses 
itself over the general surface from above downwards, invading first 
the chest and arms, then the abdomen and legs. Hands and feet are 
both affected. It usually becomes most developed on the back of the 
trunk, and probably least on the generative organs and the neighbor- 
ing portions of the abdomen. The rash usually attains its height in a 
couple of days (the sixth day of the disease), sometimes in three or four, 
and then begins to subside in the order of its appearance. Its subsid- 
ence is followed, in ten days or a fortnight, by a very fine scurfy 
desquamation, which is chiefly observable about the forehead and cheeks. 
The severity of the symptoms continues to increase so long as the rash 
itself increases ; and, with the height of the eruption, the temperature 
attains its highest point, which rarely exceeds 103° or 104°. When, 
however, the eruption begins to fade (which is for the most part on the 
sixth day, though sometimes earlier or later) the temperature almost 
suddenly falls several degrees, the severe symptoms subside, and con- 
valescence commences. The temperature in some cases at once sinks to 
the normal, but more frequently descends to 101° or 100°, at which 
elevation it remains for a day or two, and then reaches the normal limit, 
or even sinks below it. 

The catarrhal affection which attends measles is very characteristic 
and important. It commences usually in the nose, and extends as has 
been already described. In favorable cases, it produces simply the dis- 
comforts of ordinary catarrh ; but not unfrequently it assumes a more 
serious character. Sometimes it induces considerable inflammation of 
the eyes, which may terminate in chronic or in purulent ophthalmia, 
and even in their destruction. Not unfrequently it reaches the tym- 
panum, through the Eustachian tube, causing deafness and perhaps 
intense earache; upon which permanent deafness may supervene, or 
even suppuration of the middle ear. Very often croupy symptoms 
manifest themselves, or symptoms of acute bronchial catarrh, or of 
capillary bronchitis. 

The tongue is either clean, or becomes covered with a whity-brown 
fur, but does not usually get dry, still less black. Occasionally, how- 



MEASLES. 151 

ever, typhoid symptoms manifest themselves ; and the tongue may then 
become both dry and black, and sordes appear on the teeth and lips. 
There may generally be seen, early in the disease and before the. appear- 
ance of the cutaneous eruption, spotty redness of the palate and fauces, 
of the inner surface of the cheeks and lips, and of the gums. This 
often becomes uniform and intense, especially on the gums and at the 
back of the mouth, and is sometimes attended later on in the disease 
with aphtha or excoriation, and about the gums with ulceration. 
Gangrene of the mouth is met with in rare cases. Sickness is by no 
means a constant symptom, and rarely lasts beyond the period of inva- 
sion. Diarrhoea frequently comes on with the eruption, and is often 
very troublesome. Sometimes late in the disease it assumes a dysen- 
teric character. 

The urine is scanty and somewhat high-colored, and often deposits a 
sediment of urates. Albumen is occasionally present in it during the 
height of the fever. 

The eruption has on its first appearance a dusky pink color; it con- 
sists of small slightly elevated papules, which gradually increase in area 
until they attain a line or even two lines in diameter. They are darkest 
at the centre and fade towards the periphery, and are momentarily 
effaced by pressure. They are at first discrete, although arranged in 
groups which have a tendency to form irregular crescents or circles. 
When they have attained their full size, however, neighboring spots 
often run together ; and sometimes, where the rash is very thick, an 
extensive area of uniform redness results. Whilst the eruption is well 
marked, there is always more or less subcutaneous infiltration, and the 
face consequently appears swollen, and the hands and feet feel tight and 
uncomfortable. The spots fade very quickly ; but, for the most part, 
there remains some pigmentary discoloration, and perhaps, too, some 
slight tendency in the vessels of the affected spots to dilate under ex- 
citement, which collectively render indications of the rash visible long 
after the actual rash has disappeared. The skin is generally hot and 
dry. Gangrene of the vulva occasionally occurs in young children. 

The presence of frontal headache has already been adverted to. The 
chief other pains to which patients are liable are those connected with 
the presence of diarrhoea or dysentery, and those depending on otitis. 
If young children seem to be in severe and continuous pain, the latter 
complication may be suspected. Patients, especially children, are 
somewhat dull and irritable, and occasionally, during the early period 
of the eruptive stage, slightly delirious. Marked delirium is unusual, 
except in severe cases, and cases assuming a typhoid character. In 
these latter, coma sometimes supervenes, and sometimes convulsions. 
Convulsions in the eruptive stage are far more serious than convulsions 
occurring during the period of invasion. 

Measles is commonly a mild disorder, from which, if unattended 
with any serious complication, convalescence commences about the 
sixth day, and is completed by about the tenth. Sometimes it is so 
slightly developed, that its presence is only indicated by slight fever- 
ishness and fretfulness, and an inconspicuous rash about the cheeks 
and back of the neck, associated or not with catarrhal symptoms. In 



152 



SPECIFIC FEBRILE DISEASES. 



such cases, the patient may be well within three or four days from the 
first manifestation of symptoms; and it may be impossible by these 
alone to recognize his disease. Sometimes the attack of measles is 
inherently very severe; and such severity of attack occasionally charac- 
terizes epidemics. In this case, the patient manifests obvious prostra- 
tion from the beginning; the pulse becomes rapid and feeble; the 
eruption is scanty and of a dusky hue, sometimes almost black, or it 
may be petechial ; the lungs become congested ; typhoid symptoms, 
characterized by black tongue, tremulousness, and delirium, soon come 
on ; and the patient dies collapsed, perhaps comatose, at an early period. 
[Without necessarily assuming a typhoid character, an attack of 
measles is apt to occasion much more serious illness in an adult than 
in a child. Not only is the eruption tardy in making its appearance, 
but it occupies more time in extending to all parts of the body; the 
patient meanwhile suffering from excessive irritability of the stomach, 
headache, insomnia, and other distressing symptoms. During the 
recent civil war in America numbers of young recruits fell victims to 
this disease.] When the crisis is delayed beyond the sixth or eighth 
day, the cause of the delay is generally the supervention, or aggrava- 
tion, of one of the ordinary complications of the disease, especially 
laryngitis, bronchitis, lobular pneumonia, or pneumonia. These in 
fact constitute the main causes of the unfavorable results of measles. 
Death may ensue, however, from various of the other complications 
which have been enumerated, — from diarrhoea, dysentery, epistaxis, 
gangrene of the mouth or other parts, or from the results of otorrhcea. 
Pulmonary phthisis appears to be a not unfrequent sequela of measles, 
following upon the more common pulmonary or bronchial inflamma- 
tion. Diarrhoea of a very persistent and troublesome character often 
comes on after measles in children. 

31orbid Anatomy. — Internal organs manifest no post-mortem lesions 
peculiar to measles. If the patient die early, or of the malignant form 
of the disease, the blood is dark-colored and coagulates imperfectly, 
and there may be hypostatic congestion of the lungs and congestion of 
other organs. Later on, we necessarily detect the presence of lesions, 
which have been instrumental in causing death — lesions chiefly of the 
air-passages and lungs, or of the bowels. 

Treatment. — The patient, for the sake partly of counteracting spread, 
partly of preventing aggravation of the various mucous inflammations 
by exposure to cold, should be confined to his room, and, if possible, 
kept in bed until febrile symptoms have entirely subsided. His room 
should be airy and well-ventilated, but of an agreeable temperature ; 
and he should be carefully protected from draughts or chills. It is 
not generally necessary that medicines should be given; but, partly 
to promote the excretions, and partly to relieve the irritation of the 
respiratory mucous surface, a mixture, containing a small quantity of 
ammonia with the acetate of ammonia, to which may be added ipecacu- 
anha wine and minute doses of laudanum (very minute in cases of 
young children), may be frequently administered; for the soreness of 
the throat, a little black currant jelly may be used, and the patient 
may gargle with warm milk. In consequence of the tendency to 



EPIDEMIC ROSEOLA. 



153 



dysenteric diarrhoea purgatives should be avoided or employed with 
great caution. The diet should be mainly bread and milk, beef tea, 
and other such fluid, bland, nutritious articles of diet. When con- 
valescence is in progress, vegetable tonics are useful, and a substantial 
diet must be gradually adopted. The various complications of the 
disease, and its sequelae, will require each its appropriate treatment, 
which need not differ materially from that of the same affection occur- 
ring independently; only it is important to recollect that depletory 
measures are in this case specially injurious. When the eruption is 
dusky, or comes out imperfectly, and the patient at the same time 
appears to be very ill, a warm bath is often of great service. It may 
also be beneficial when, late in the disease, convulsions come on. 
When the patient shows signs of exhaustion, and especially therefore in 
the malignant form of the disease, and when typhoid symptoms are 
present, stimulants are imperative. In most cases of measles they are 
quite unnecessary. 



EPIDEMIC ROSEOLA. (Rotheh. Rubeola.) 

Definition. — A contagious disorder, having a close resemblance to 
measles, with which it is often confounded. 

Causation. — This disease is said to occur chiefly in hot seasons, and 
to affect children much more readily than adults; it is doubtful, how- 
ever, whether season or age exerts any special influence over it. It 
certainly spreads by contagion, and doubtless, therefore, depends on a 
specific virus. Its contagiousness is apparently much less active than 
! that of measles. 

Symptoms and Progress. — The incubative period of epidemic roseola 
is probably about a week. Its invasion is, in a considerable number 
of cases, coincident with the appearance of the rash. In some cases, 
however, the appearance of the rash is preceded for a day or two by a 
feeling of poorliness; the patient has a headache, or is feverish, and 
may even have rigors; or he complains of cold or catarrh, and, accord- 
ing to Trousseau, may, if a child, have diarrhoea and convulsions. 
These latter occurrences, however, must be very rare; and, indeed, 
among the chief distinctions between this affection and measles are 
the slightness, the want of character, and the uncertain but always 
short duration of its stage of premonitory fever. 

The rash generally appears first on the sides of the nose and adjoin- 
ing parts of the cheeks, upon the lower region of the forehead, and the 
I lateral aspects of the inferior maxilla, but it shows itself almost, if not 
I quite, as early on the forearms and hands and corresponding parts of 
:j the lower extremities, and rapidly diffuses itself over the whole cuta- 
I neous surface. It attains its height usually on the second day, and, in 
j the course of the next two, three, or four days, rapidly disappears. 
P The rash has much resemblance, in tint and general appearance, to 
that of measles; it does not assume, however, the crescentic grouping 
. which is characteristic of that affection. The spots, which fade on 



154 



SPECIFIC FEBRILE DISEASES. 



pressure, are of a dusky red or purplish hue, of irregular shape, and 
often clustered, sometimes running together over considerable tracts, 
and vary in size from mere points up to a line or more in diameter. 
They are, for the most part, scarcely elevated above the general level 
of the skin ; but occasionally, and more especially on the face, form 
considerable papular or tabular elevations. The rash is generally most 
abundant on the face, where it is often confluent, and on the fore- 
arms and legs (especially about the ankles and wrists), where, also, 
there is often a similar tendency to confluence. It is less thickly de- 
veloped elsewhere ; but no part is free ; and generally abundant dis- 
crete spots may be observed on both the palmar and the dorsal aspects 
of the hands and fingers, and on the corresponding parts of the feet 
and toes. It is attended with considerable itching, and is often fol- 
lowed by branny desquamation. The patient does not generally com- 
plain much, or at all, of soreness of the eyes, or of lachrymation, nev- 
ertheless there is nearly always marked congestion of the conjunctivae. 
There is frequently a little sore throat, and sometimes red puncta, or 
more or less diffused redness, may be recognized on the soft palate and 
fauces. There is not, as a rule, defluxion from the nose, or sneezing, 
or, if these symptoms are present at all, they are by no means promi- 
nent. There is often a little cough. During the first day or two after 
the appearance of the rash, the patient may be somewhat feverish, with 
slightly elevated temperature, headache, or swimming in the head, and 
other slight symptoms referable to fever, but not unfrequently he feels 
and expresses himself as being perfectly well. The affection is unat- 
tended with complications, subsides ordinarily within a week, and has 
no sequelae. 

Epidemic roseola has been described as a hybrid of scarlet fever and 
measles, and some have regarded it literally as such. There is, how- 
ever, really little resemblance between it and scarlet fever. Its resem- 
blance to measles, on the other hand, is very close. It differs from 
measles, chiefly, in the slight development of its initiatory fever, in 
the almost complete absence of coryza, in the arrangement of its erup- 
tion, and in the general mildness of its symptoms ; but these are 
chiefly differences of degree, and such as might be observed in a very 
slight case of measles. The main distinction is this : that roseola and 
measles are mutually unprotective ; that roseola is of frequent occur- 
rence in children who have had measles only a short time previously ; 
and that when it breaks out in a family or school of children, of whom 
some have had measles, and some not, it attacks them indiscrim- 
inately, and with equal mildness, and never becomes developed into 
true measles. 

No special treatment is needed. 



SCARLET FEVER. (Scarlatina. Febris Rubra.) 

Definition. — A contagious malady, characterized mainly by a general 
punctiform scarlet eruption appearing usually on the second day, and 
by inflammation of the fauces and tonsils. 



SCARLET FEVER. 155 

Causation and History. — Scarlet fever was, up to the sixteenth or 
seventeenth century, confounded with measles. They are, however, 
two perfectly distinct diseases, and are now fully recognized as distinct. 
"Whatever its original source, or however it may formerly have been 
limited in area, it is now general throughout the world, occurring in 
most parts sporadically, but breaking out frequently into epidemics of 
greater or less severity. Its prevalence seems independent of season 
and of climate, but, as with other infectious epidemic disorders, is 
largely promoted by overcrowding and poverty. Children suffer from 
it in much larger proportion than adults, not, however, because there 
is any special proclivity to it in childhood, but because, from its fre- 
quent prevalence, and highly infectious nature, the great majority of 
children become exposed to its influence during the first few years of 
life, contract it, and thus acquire protection. Scarlet fever rarely 
occurs a second time, yet second, and even third, attacks have been 
noticed. It is, however, a common observation that protected attend- 
ants on scarlatinal patients frequently suffer from more or less sore throat 
during the period of their attendance, and the question therefore natu- 
rally arises, as to whether such attacks should not be regarded as abor- 
tive attacks of scarlet fever. They probably are so. The contagion of 
scarlet fever is very powerful and very diffusive. It may be carried 
considerable distances by the atmosphere, certainly through the whole 
dimensions of a large ward, and it clings to clothes and other fomites 
with considerable tenacity, and may thus lie latent, yet capable of 
action, for weeks and months. Scarlet fever occurs only as the result 
of contagion, conveyed usually by the means which have been already 
indicated. It seems that it may also be transmitted by direct inocu- 
lation ; for there is reason to believe that it can be imparted by insert- 
ing the fluid of the scarlatinal vesicles beneath the cuticle of persons 
who have not yet had it ; and it is certain that women, at the time of 
parturition, are especially liable to take it, receiving it then, in some 
cases, apparently direct from the fingers of the accoucheur. The period 
at which a scarlatinal patient begins to be infectious is uncertain. We 
know, however, that his infectiousness is not very well marked during 
the first two or three days. It probably increases with the develop- 
ment of the rash and sore throat, and pretty certainly does not cease 
until desquamation has been completed. 

Symptoms and Progress. — The latent period of scarlet fever is shorter 
than that of most diseases of the same- class. It usually varies between 
six and eight days, is rarely more prolonged, but very often shorter. 
Many cases, indeed, of undoubted authenticity have been recorded, 
in which it certainly did not exceed twenty-four hours. In puerperal 
cases, and probably also in persons suffering from large wounds, the 
period of latency seems generally to be of very short duration. Scarlet 
fever varies, perhaps more than any other like disease, both in the 
degree of severity of its attacks, in the symptoms which it presents, 
and, in fatal cases, in the cause and period of death. In a typical case 
of the disease, the invasion is sudden and marked usually by chills, 
vomiting, and sore-throat ; with which are associated, or on which 
[ soon supervene, great rise of temperature, general dryness of skin, 



156 



SPECIFIC FEBRILE DISEASES. 



much acceleration of pulse, languor, drowsiness, frontal headache, gid- 
diness, aching in the limbs, slight coating of tongue, thirst, anorexia, 
and sometimes diarrhoea. The most characteristic of these symptoms 
are the sore-throat and vomiting ; the remarkable rise in the frequency 
of the pulse, which may attain 120 in the adult or 160 in the child ; 
and the rapid augmentation of temperature, which may reach very 
nearly 105° during the first day. The disease is sometimes ushered in 
with rigors, and not unfrequently there is some delirium or even ten- 
dency to coma. 

On the second day the rash makes its appearance, first on the chest, 
and simultaneously or very soon afterwards on the forearms, lower 
part of the abdomen, and upper part of the thighs. It becomes general 
in the course of four-and-twenty hours, more or less, and attains its 
full development on the third or fourth day. The rash consists, in the 
first instance, of very minute rosy papules, due for the most part (as 
those of so-called " goose's skin") to the conical elevation of the cutis 
around the points of emergence of the hairs ; they are hence closely 
and pretty uniformly arranged, but discrete and separated from one 
another by healthy skin. They soon, however, increase in size and 
intensity of redness, and presently, blending with one another by their 
congested margins, give to the surface a uniformly scarlet hue. The 
papular character of the rash is still, however, for the most part, dis- 
tinguishable on close inspection. Not unfrequently the papulae on the 
chest and sides of the neck become vesicular; and generally the rash 
is attended with more or less infiltration and thickening of the cutis. 
The vivid redness of the skin disappears readily with pressure, as by 
drawing the point of the nail firmly along te surface ; hand the line 
formed by this latter process remains anaemic for a second or two. The 
scarlatinal rash varies much in its intensity and in its diffusion. It is 
sometimes very pale and almost imperceptible, and may be strictly 
limited to the part in which it generally first appears. When general, 
it is most vivid on the neck, chest, abdomen, and inner aspects of the 
thighs and arms. It is rarely distinct upon the face, which, however, 
often presents irregular patches of redness. The feet and hands are not 
unfrequently stiff with the rash, and its attendant oedema. 

While the rash is attaining its full development, the other symptoms 
are all undergoing aggravation. The heat rises ; the pulse increases 
in frequency ; the respirations become more rapid ; the tongue, which 
was at first covered (excepting at the tip and edges) with a thickish 
whitey-brown fur, soon cleans, and towards the end (that is in four or 
five days from the invasion) becomes morbidly red, with swollen pa- 
pillae, and presents the remarkable strawberry-like appearance so char- 
acteristic of this disease. At this time too it is apt to become dry. 
The soreness of the throat increases ; and, on inspection, more or less 
vivid or dusky redness of the pillars of the fauces, of the soft palate 
and uvula, and of the tonsils, is apparent. These parts, moreover, 
swell; and the tonsils often enlarge as in common quinsy, and present 
here and there on their surface imbedded, or adherent, spots of inspis- 
sated secretion. With the faucial swelling and inflammation are 
usually associated pain and difficulty in swallowing, fulness and ten- 



SCARLET FEVER. 



157 



derness behind the angles of the jaw, and some enlargement of the 
neighboring lymphatic glands. The muscular system of the patient 
grows weaker, his limbs tremulous; he becomes and looks dull and 
stupid, or restless, is forgetful and slow to answer; delirium probably 
increases ; vomiting is now not common * but thirst and anorexia con- 
tinue ; and the bowels, though variable, are generally constipated. 

From the fourth to the sixth day of the disease, the rash begins to 
fade; and it disappears, according to its intensity and the date at which 
it attained it maximum, between the sixth and the twelfth day of the 
disease, or between the fifth and the tenth day from the commencement 
of the rash. It is frequently about this time that, if the case be going 
on badly, the patient passes into a typhoid condition, or the throat com- 
plications become serious — the tonsils suppurating or ulcerating or 
sloughing — or the urine becomes albuminous, and anasarca and uraemia 
supervene. If, however, the case be going on favorably, all the symp- 
toms now gradually subside; the temperature, with slight daily remis- 
sions, gradually becomes normal or even subnormal; the pulse by 
degrees sinks to its healthy rate or below it; the soreness and inflamma- 
tion of the throat subside; the tongue becomes clean and moist; thirst 
abates; appetite returns; and delirium, and other symptoms referable 
to the nervous system, disappear. 

With the disappearance of the rash, desquamation commences. It 
may, indeed, be observed on the chest before the rash has quite left 
other parts of the surface. It commences usually on the neck and 
chest; whence it spreads to the rest of the trunk, and then to the limbs, 
occurring lastly in the palms of the hands and soles of the feet. Des- 
quamation always takes place in considerable flakes, the size of which 
is greater according as the epidermis is thicker. Hence these are smallest 
and most delicate on the chest and abdomen, larger on the limbs, and 
from the hands and feet the epidermis occasionally separates in the form 
of a glove. The period of desquamation is of very various duration ; 
sometimes it is completed in one or two days, not unfrequently it ex- 
tends over a week or two, and occasionally it is prolonged for several 
weeks. It is a period of some danger ; for it is chiefly in its course 
that the urine becomes albuminous, that dropsy and uraemia threaten, 
and that rheumatism and other serious sequela? are liable to come on ; 
moreover, there is good reason to believe that the desquamating parti- 
cles of skin retain the contagium of the disease, and are highly infectious. 

We will now briefly pass in review some of the more important phe- 
nomena of scarlet fever. The great acceleration of the pulse, especially 
in children, is a notable feature of the disease; the pulse rises on the 
first day probably to between 100 and 120, in children still higher; 
and it continues generally to increase, up to the time of full develop- 
ment of the rash, attaining a rate sometimes of from 120 to 160, and 
even beyond that; after which, if the case go on favorably, it gradually 
falls. This great acceleration of pulse is not necessarily an indication 
of danger. Nevertheless, unusual rapidity with marked weakness of 
pulse, especially when associated with other unfavorable symptoms, is 
of grave import. 

Respiration is always more or less accelerated, but there is not neces- 



158 



SPECIFIC FEBRILE DISEASES. 



sarily any cough or difficulty of breathing, Sometimes, however, in 
cases of unusual intensity (as also in pyaemia and other cases of so-called 
" blood poisoning ") the respirations become very rapid and shallow, J 
and the inspirations attended with dilatation of the nostrils, and a sniff- 
ing or sucking sound — conditions which, unassociated with distinct pul- 1 
monary lesion, indicate very great danger. During the period of per- 
sistence of the eruption, or during the later periods of the disease, 
inflammation may extend to the larynx and trachea, and produce the 
usual symptoms of laryngitis; or coryza, bronchitis, or lobular or lobar 
pneumonia, with their several groups of symptoms, may supervene. 

Thirst and loss of appetite are always present in a greater or less 
degree. Vomiting is for the most part a characteristic feature of the 
invasion, and few children fail to suffer from it. It does not, however, 
usually persist. Diarrhoea, again, is not uncommon at the commence- 
ment; after which, the bowels are generally, but by no means neces- 
sarily, constipated. The tongue varies in character. In very mild 
cases, it is only slightly furred, and soon cleans, without ever display- 
ing the strawberry-like appearance. Sometimes again, it very early 
becomes thickly coated, dry, and even black — sordes appearing at the 
same time on the teeth and lips. More frequently as has been pointed 
out, it is coated at the beginning, and on the fourth or fifth day be- 
comes clean and unnaturally red, with prominent and swollen papillae; 
after which, it may either gradually acquire the normal characters, or 
become dry and mahogany-like, and assume a well-marked typhoid 
appearance. The soreness of the throat causes difficulty and pain in 
swallowing, and a nasal condition of voice. It involves all the parts 
at the back of the mouth, the fauces, and the upper part of the pharynx ; 
but does not generally include the larynx. The tonsils chiefly suffer ; 
and, as has been pointed out, they generally become enlarged, and 
present on the surface opaque patches, which have been secreted by the 
glandular structure. In mild cases, the soreness may be very slight, 
and may speedily subside. Very often, however, sometimes at the be- 
ginning, more frequently in the second or third week, the tonsils sup- 
purate, or ulcerate, or become sloughy ; or abscesses and buboes form in 
their neighborhood; or a false membrane appears upon the surface and 
extends to other neighboring parts. 

The urine, during the febrile stage of the disease, is scanty and high- 
colored, contains a diminished quantity of chlorides, and, according to 
Dr. Gee, no necessary increase of urea. Subsequently it becomes more 
abundant and of lower specific gravity. Albumen is frequently present 
in it, and its presence- is a matter of considerable importance. It ap- 
pears to have no particular connection with the degree of severity of 
the attack. Indeed, many of the severest cases escape it altogether, 
and many of the mildest suffer severely. The time of the first appear- 
ance of albumen varies. It has been detected on the second or third 
day of the disease, but commences far more commonly in the course of 
the second or third week, or during the period of desquamation. Its 
amount varies, as also does the period during which it persists. The 
urine is not unfrequently smoky. Under the microscope are found 



SCARLET FEVER. 



159 



hyaline and sometimes epithelial casts of the renal tubules, and usually 
blood-corpuscles, or casts containing altered blood. 

The characters of the rash have been already fully described ; it 
must be added that, during the height of the disease, the skin is 
generally dry and feels pungently hot, and that in some of the malig- 
nant cases petechia? make their appearance. 

The temperature of the body attains a greater height in scarlet fever 
than in any other disease of the same class; it frequently reaches 104° 
or 105° when the eruption is fully developed, and occasionally rises to 
110° or even 112°. It differs in its course from that of small-pox, in 
the fact that it rises, instead of falling, when the rash appears; and 
from that of measles, that it subsides slowly after the rash has reached 
its acme, instead of undergoing a sudden fall. 

The patient complains of soreness of throat, and has some headache 
and giddiness, and general aching of his limbs ; but the pains are not 
so severe as in many other febrile disorders. In the beginning of the 
disease he is generally restless and sleepless, and often presents a little 
delirium. When the eruption comes out, and during its persistence, 
the patient may still be restless and excited, or dull and inclined to be 
comatose, or he may present more or less delirium. In some severe 
cases, violent delirium manifests itself amongst the earliest symptoms. 
Occasionally, in children, convulsions come on early in the disease ; they 
are rarer, however, than at the commencement of measles or small- 
pox, and are far more serious — indeed are generally followed by a fatal 
result. In cases which are about to prove fatal, coma not unfrequently 
supervenes, or delirium, or convulsions. Tremors of the muscles, sub- 
sultus, and picking at the bed-clothes occur in serious cases. 

No. known disease is more unequal in its attacks than scarlet fever. 
In individual cases it often proves one of the mildest and most trivial 
of ailments, and often one of the most terrible and rapidly fatal of 
maladies. In one household all the members may have it so slightly 
that they scarcely acknowledge to themselves that they have been ill ; 
and in another not one that is attacked survives. And varieties of 
this kind characterize epidemics. Thus, in many cases, the disease 
spreads rapidly through a village or a town, or over a large extent of 
country, and its attacks are so mild that scarcely a death results ; while 
in other cases, the epidemic is characterized by great malignancy and 
terrible mortality. 

The mildest cases have been termed latent scarlet fever. These are 
cases so slightly developed that they would probably not be recognized 
as scarlet fever at all, were it not for the fact either that they occur 
while scarlet fever is prevailing, or that they impart scarlet fever, or 
that desquamation, or albuminuria with anasarca, or both, supervene. 
The patient may suffer from slight febrile symptoms only, lasting for 
a day or two, with which may, or may not, be associated evanescent 
traces of a rash, or some degree of roughness of the throat. It is a 
question, which has already been raised, whether the sore throat which 
protected attendants on scarlatinal cases so frequently experience is not 
the visible sign of latent scarlatina, or rather, perhaps of the disease in 
a modified form. 



160 



SPECIFIC FEBRILE DISEASES. 



The more ordinary forms of scarlet fever are those to which the pre- 
vious detailed description applies. The symptoms of invasion are well- 
marked, the rash is abundantly developed, the throat and tongue are 
typically affected, and the rash disappears between the sixth and the 
twelfth day of the disease, to be followed by desquamation. But cases 
of medium severity may present considerable varieties among them- 
selves. Thus in some, while every other characteristic symptom is 
present, the throat may escape ; in some, while the throat surfers se- 
verely, the eruption may be very imperfectly developed. The former 
cases are often distinguished by the epithet of scarlatina simplex ; the 
latter by that of scarlatina anginosa. 

The epithet malignant is commonly given to those cases of scarlet 
fever in which the symptoms are unusually severe, and death tends to 
come on rapidly. It is somewhat loosely applied, and embraces cases 
of widely different characters. The most terrible of such cases are 
probably those in which the patient seems to be struck down by the 
severity of his attack, and dies collapsed during the first three days of 
the disease — sometimes on the first day, often before the rash has had 
time to appear or to develop, or before the affection of the throat has 
become a special cause of complaint. The symptoms of invasion are 
severe; the vomiting is probably distressing ; the chills or rigors are 
unusually well-marked; the temperature attains an extraordinary ele- 
vation ; the pulse becomes extremely rapid and weak, the respirations 
quick, shallow, and suspirious ; prostration and muscular debility are 
extreme, there is tremulousness of the muscles and jactitation ; the 
face is dusky and the expression anxious. The patient is sometimes 
sensible, almost to the last ; sometimes there is from the beginning 
fierce or muttering delirium, which lapses before death into coma, oc- 
casionally preceded by an attack of convulsions. Another variety of 
malignant scarlet fever is that in which the throat is gravely implicated. 
The throat-affection may be serious from the first ; but more frequently, 
in a case which presents no very unusual features at the beginning, it 
undergoes aggravation either at the acme of the fever, or during the 
subsidence of the rash, or even on its disappearance. The nature of the 
affection has been already adverted to. There may be abscess of the 
tonsil, or ulceration or gangrene, with oedema of the surrounding tis- 
sue ; and supervening on these, the glands in the neck may inflame 
and suppurate, and sinuses form. Under these circumstances the pa- 
tient is apt to fall rapidly into a typhoid condition, and thus die ; or 
he may be carried off by oedema of the glottis, perforation of an artery, 
or pyaemia. Scarlet fever occurring at or just subsequently to partu- 
rition is excessively fatal, and constitutes one of the gravest forms of 
so-called " puerperal fever." It does not, however, appear to be spe- 
cially dangerous during pregnancy, or to lead to abortion. 

The sequela? of scarlet fever are numerous and important. It is 
difficult, however, to make any clear distinction between the complica- 
tions which form a part of scarlet fever, and have been already de- 
scribed, and the phenomena which are simply secondary. It is need- 
less to repeat what has been said about bronchitis and pneumonia and 
ulceration of the throat, all of which are apt to complicate the disease 



8CAKLET FEVER. 



161 



In its later stages. We will briefly consider the more important of 
those sequelae which have not been referred to. 1. The conjunctivae 
not u n frequently inflame in the course of scarlet fever ; and occasionally 
in the second or third week of the disease the ophthalmia becomes in- 
tense and purulent; and sloughing of the corneae may result. 2. In- 
flammation sometimes extends along the Eustachian tube to the tym- 
panic cavity, producing earache or otitis, with, it may be, disease of 
the petrous bone and sooner or later abscess of the brain, pyaemia or 
some other fatal lesion. Inflammation may extend also to the nose, and 
produce chronic catarrh of its mucous surface. 3. Inflammation of 
the pericardium or of the pleurae (the latter often purulent) is not un- 
common. 4. During the decline of the fever, or even during the 
period of convalescence, rheumatism is very apt to supervene. This 
differs in no respect from ordinary rheumatism, involves successive 
joints and in many cases the pericardium or the cardiac valves, and 
adds seriously to the fever and distress of the patient. To scarlatinal 
rheumatism, as to other varieties of rheumatism, chorea or embolism 
occasionally succeeds. 5. The most important sequelae of all are, un- 
doubtedly, anasarca and uraemic poisoning. We have pointed out that 
in a large proportion of cases (and for the most part in the second or 
third week) the urine becomes albuminous. Now this condition gen- 
erally passes off without any ill result. But not unfrequently, and 
more frequently after mild than after severe cases, anasarca comes on 
with uraemia, which may presently be attended with severe headache, 
and followed by epileptiform convulsions and death. Under judicious 
treatment the albuminuria and the dropsy may subside; but sometimes 
the albuminuria becomes permanent, and the kidneys undergo slow 
disorganization ; sometimes anasarca survives the disappearance of the 
albuminuria; sometimes it becomes developed in those who have never 
had albumen in the urine. Uraemic convulsions generally involve a 
fatal issue. 

Morbid Anatomy. — On post-mortem examination of scarlatinal pa- 
tients most organs are found fairly healthy. The liver and kidneys 
may be somewhat softer than natural, and the blood imperfectly coagu- 
lated. Yet, well-formed fibrinous clots are not uncommon in the right 
ventricle. In so-called "malignant" cases, there may be collapse and 
hypostatic congestion of the lungs, and haemorrhage into and at the 
surface of internal organs. The throat generally presents distinct 
traces of inflammation and ulceration. The solitary intestinal glands 
and Peyer's patches are often somewhat enlarged. The only other 
morbid appearances (and they are sufficiently important) are such as 
are connected with the sequelae and complications of the disease. 
These, however, though common in scarlet fever are not peculiar to it, 
and will be considered with the special diseases of the various organs 
to which they belong or under other appropriate heads. 

Treatment. — Whenever scarlet fever breaks out among a number of 
susceptible persons, it is important that the sick should be at once 
separated from the sound. The patient should be placed in a suitable 
room, at the top of the house if possible, and if possible should have a 
floor to himself. All the usual measures should be taken as regards 

11 



162 



SPECIFIC FEBRILE DISEASES. 



nursing, ventilation, disinfection, cleanliness, and removal of surplus 
furniture. He should be kept strictly in bed, with only so much cov- 
ering as is absolutely necessary. His diet should consist of milk, 
beef tea, eggs, and other such articles. And for medicine, acetate of 
ammonia or nitrate or chlorate of potash in solution may be servicea- 
ble. Some strongly recommend ammonia in large and frequent doses ; 
and some dilute hydrochloric acid, or the perchloride of iron. Ice is 
often useful to allay vomiting. To relieve the soreness of the throat, 
ice, or the inhalation of steam, or warm milk slowly swallowed, or as- 
tringent or antiseptic gargles may be employed. The patient is also 
generally benefited by tepid sponging, or by the tepid douche bath. 
If the bowels are much constipated they should be relieved by laxa- 
tives ; if there is diarrhoea they should be restrained by opium or other 
astringents. When convalescence is taking place, it is recommended 
to keep the body well greased in order to prevent the dissemination of 
the flakes of cuticle. The practice is a good one, and may be associated 
with the daily use of warm baths. Tonics must now be had recourse 
to, and the diet should be nutritious and include a fair proportion of 
solid food. ' It is during this period that the dangers of rheumatism 
and of dropsy are greatest. It is important, therefore, that the patient 
should be kept warm, that he should not be exposed to draughts, that 
he should keep his room, either confined to bed or incased in flannel, 
and that the excretory functions should be carefully attended to, until 
the period of desquamation has come to an end. 

In most cases stimulants are not needed ; in malignant cases, how- 
ever, and in all cases where the muscular debility is great, and there 
is a tendency to collapse, or to the coming on of typhoid symptoms, 
they are imperatively demanded. 

In the severest cases of the disease, however, all treatment is futile; 
and in the milder cases, the care of the physician must be directed, 
not so much to the cure of the disease, as to the relieving of discom- 
fort, and to the obviation, by precautionary measures, of the complica- 
tions and sequelae which so commonly arise, and are so dangerous. 

If there be nasal catarrh, with discharge, it is well to syringe the 
nostrils with warm water, or water containing chlorate of potash, or 
nitrate of silver, or some antiseptic. If the throat be ulcerated or 
gangrenous, solution of perchloride of iron, or of nitrate of silver, or 
even the latter in a solid form, or hydrochloric or nitric acid, may, 
according to circumstances, be applied. Warm fomentations or poul- 
tices should be employed externally, and if there be suppuration in 
the glands or connective tissue behind and below the jaw, a puncture 
or incision should be made. Otorrhcea, rheumatism, renal dropsy, and 
ursemic convulsions must be treated as these affections are treated 
when they arise under other circumstances. And so with regard to 
other complications; only, it must not be forgotten that these affec- 
tions, occurring as complications, bear depletion less, and need stimu- 
lation more, than do the same affections when they are of spontaneous 
or idiopathic origin. 



SMALL - POX. 



163 



SMALL-POX. ( Variola.) 

Definition. — A specific fever, spreading by contagion, and charac- 
terized especially by the appearance on the third day of a papular 
eruption, which gradually becomes pustular, and attains its full devel- 
opment on or about the eleventh day of the disease. The eruption 
shows itself also in the mucous membrane of the mouth, fauces, and 
larynx. 

Causation and History. — As with many other of the infectious 
fevers, the history of small-pox cannot be traced further back than 
the Christian era. The first recorded epidemics, indeed, seem to have 
occurred in the sixth century. Since then it has never disappeared 
from among us, has been carried from Europe and Asia over all parts 
of the world, and, up to within a recent period, has formed one of the 
most formidable and fatal of pestilences. The disease was robbed of 
many of its terrors by the practice of inoculation, introduced first into 
this country, early in the eighteenth century, by Lady Mary Wortley 
Montague, who had witnessed the efficacy of the procedure in Con- 
stantinople, whither it had been imported from Persia and China. It 
was still more marvellously controlled by the application of Jenner's 
discovery, made at the end of the same century, of the protective in- 
fluence of vaccination ; since the general adoption of which, small-pox 
has become a comparatively rare and unimportant affection. It still, 
however, maintains all its old virulence when it attacks those who are 
not protected by vaccination or by a previous attack of the disease, 
and all its old epidemic violence when it is introduced among suscep- 
tible communities. Small-pox has no special predilection for age or 
sex; it is said, however, that dark-skinned races, and especially ne- 
groes, surfer more severely from it than the denizens of temperate cli- 
mates. All persons, indeed, are liable to take it, unless protected in 
one or other of the ways which have just been adverted to, or (as very 
rarely happens) by some peculiar constitutional insusceptibility. In- 
stances, however, are not, on the whole, uncommon, in which persons 
have a second, and even a third, attack — such attacks being for the 
most part mild; and it is a curious circumstance that, not unfrequently, 
those who have enjoyed immunity from the disease for many years, in 
spite of constant exposure to it, finally contract it, and then have it in 
a very severe form. Whatever the source of small-pox may originally 
have been, there is no doubt whatever that now it originates solely in 
contagion, and that the contagion may be conveyed either through the 
atmosphere or by fomites, or by direct inoculation with the contents 
of the variolous pustules. Few diseases, indeed, are more virulently 
contagious than small-pox, and there is none whose virus remains 
effective for a longer period. 

Symptoms and Progress. — The period of latency of the inoculated 
disease has been distinctly ascertained to be seven or eight days. On 
the second day after inoculation a small papule shows itself at the seat 
of puncture, which, by the fourth day, is converted into an umbilicated 
vesicle. On the seventh day the vesicle has formed a pustule, and 



164 



SPECIFIC FEBRILE DISEASES. 



about the same time the lymphatic glands above have become swollen 
and tender, and on this day, or the eighth, rigors, and other symptoms 
indicative of the invasion of the disease, occur. About the tenth or 
eleventh day the pustule is fully developed, and at the same time the 
general variolous rash appears. By the fourteenth day the pustule has 
dried up into a scab. The period of incubation is always longer when 
the disease has been acquired in the usual way. It is generally con- 
sidered then to range between ten and sixteen days. According to 
Mr. Marson, it is almost invariably twelve days. The facts connected 
with inoculation prove that the variolous contagium is present, in a 
concentrated form, in the mature pustules. There can, therefore, be 
little doubt that small-pox is especially infectious about the period of 
maturation. It is probably, however, contagious during the whole 
period of its duration, from the first signs of invasion up to the sepa- 
ration of the last scab. 

The incubative stage of small-pox is, with very rare exceptions, 
unattended with symptoms. In the exceptional instances, the patient 
may suffer from languor, peevishness, and other vague signs of illness. 
The invasion is more or less sudden, and is indicated by rise of tem- 
perature, chills, or rigors, followed by, or alternating with, great heat 
of skin, and generally (in adults) copious perspiration ; by severe sick- 
ness, with anorexia, thirst, and constipation, or (in children) diarrhoea ; 
by headache, aching of the limbs, and intense pain in the lumbar 
region of the spine; by drowsiness, and not unfrequently delirium, 
stupor, or coma, and (in children) convulsions. There is sometimes 
maniacal excitement. The most characteristic of the above symptoms 
are the vomiting, constipation, and acute lumbar pain. It is import- 
ant, too, to note the frequency of perspirations and of convulsions, 
which for the most part are unattended with danger to life. The 
symptoms of this stage are severe in proportion to the severity of the 
attack which they usher in. Cceteris jxiribus, therefore, the higher the 
temperature, the more persistent the vomiting, the acuter the pain in 
the back, the more pronounced the implication of the brain, the more 
quickly will the disease assume grave proportions, and the greater will 
be its intensity, and the prospect of a fatal issue. Absence or scanti- 
ness of perspiration, and the presence of diarrhoea in adults, are also 
indications of a severe attack. 

The symptoms above described, in the great majority of cases, attain 
their maximum on the third day — the day on which the characteristic 
rash first manifests itself. In a small proportion of cases, and these 
are for the most part fatal cases of great malignancy, the eruption 
appears on the second day ; and occasionally it is delayed to the fourth 
or even later. In modified small-pox, it is not unusual to find the 
appearance of the true eruption preceded for a day or two by a roseo- 
lous efflorescence, which has some resemblance to the scarlatinal rash. 
And in cases which threaten to be unusually severe there may be on 
the second or third day of the disease, 1st, a subpapular patchy red- 
ness on the face and elsewhere, which is then almost indistinguishable 
from the rash of measles, but which is in fact the commencement of 
the small-pox eruption in a papular form ; or, 2d, an abundant pete- 



SMALL -POX. 



165 



chial rash chiefly about the sides of the chest and abdomen and on the 
loins. The rash commences, however, usually on the third day in the 
form of minute reddish papules, which are first visible on the face, 
head, neck, and wrists, and in the course of the next two days invade 
successively the upper part of the chest, the arms, the rest of the trunk, 
and the lower extremities. The spots are first hard, solid, hemispher- 
ical, or acuminated, and feel like shot imbedded in the skin; they 
gradually increase in size, and in the course of two or three days 
become vesicular ; then, still gradually increasing in area, their con- 
tents become opaque and milky, and about the sixth day (eighth day 
of the disease) distinctly purulent. With their conversion into pustules, 
there is a marked extension of inflammation ; each pustule becomes 
surrounded by a deep-red areola, and the subjacent tissues swollen 
with inflammatory effusion. The pustules increase in size, and the 
surrounding inflammation augments, up to about the ninth day 
(eleventh day of the disease). The process of maturation, as it is 
balled, is then completed. The above remarks apply more particu- 
larly to the eruption on the face; on the lower part of the trunk, and 
on the extremities, its several stages occur somewhat later. The 
eruption of small-pox is always more abundant and close-set on the 
face and neck than elsewhere ; and is generally, even in severe cases, 
scanty on the lower part of the trunk. When it is sparse the papules 
often appear, as those of measles, in. crescentic groups. When, how- 
ever, it is more thickly arranged this character is not evident; and, if 
the primary papules are very much crowded, the pustules which result 
from them tend to coalesce, and thus to form extensive tracts of sup- 
puration, in which the limits between the constituent pustules are 
scarcely or not at all distinguishable. When the pustules remain 
distinct from one another on the face, the attack of small-pox is termed 
discrete; when they run together in the same situation, it is called 
confluent. The pustules of discrete small-pox are always larger than 
those of the other variety, and the surrounding inflammatory areola is 
more obvious. The confluent form, however, is always much more 
severe, and attended with far greater subcutaneous swelling and ulti- 
mate destruction of tissue. The face, indeed, and especially the eyelids, 
are apt to become enormously swollen ; and the hands, too, are often 
so much enlarged and so tense that the patient cannot close them. 
The variolous rash is not limited to the skin, but is generally devel- 
oped also, more or less abundantly, on the mucous surface of the nose, 
mouth, fauces, pharynx, and even on that of the larynx and trachea, 
and sometimes upon the conjunctivse. The fully-developed cutaneous 
pustules are circular in outline, unless altered in form by mutual coal- 
escence or other accidental circumstances, vary from about J to J inch 
in diameter, are somewhat flat, and mostly depressed in the centre or 
umbilicated. In some cases their contents, even from an early stage, 
are mixed with blood; and not unfrequently they are associated with 
petechia? and vibices. 

In all cases of small-pox, there is, on the first appearance of the 
rash, a sudden diminution of the severe symptoms which characterized 
the invasion ; the temperature falls, and becomes in some cases nearly 



166 



SPECIFIC FEBRILE DISEASES. 



normal, the pulse lessens in frequency, the vomiting ceases, the febrile 
pains and the pains in the back subside, delirium and other nervous 
symptoms disappear, the patient seems to be convalescent, and his 
appetite perhaps returns. At the same time, however, the cutaneous 
eruption is producing some inconvenience; he begins to complain of 
soreness in the mouth and tongue, with pytalism ; his throat becomes 
painful, his voice hoarse ; and a ringing or metallic cough probably 
comes on — phenomena which are all due to the involvement in the 
rash of the mucous surface of the upper parts of the respiratory and 
alimentary tracts. The degree in which the symptoms of invasion 
subside, and the duration of the period of their abeyance, depend on 
the severity of the attack. In very mild cases, the pocks, at the period 
at which they usually suppurate, begin to contract and dry up, and 
there may then be no interruption to the favorable progress of con- j 
valescence. In cases of medium severity, the period of apparent 
convalescence continues up to the sixth or seventh day of the rash 
(eighth or ninth of the disease) — the time at which the maturation of 
the pustules commences. It is then interrupted by a sudden recur- 
rence of febrile symptoms, which last for some three or four days, or 
until about the completion of maturation. This is the period of 
secondary fever, and is marked by chills or rigors, increase of temper- 
ature (which may even surpass that of the period of invasion), accelera- 
tion of pulse, dry furred tongue, and more or less delirium. When 
the disease is of the confluent kind, the remission of symptoms at the 
commencement of the eruptive stage is very slight; the temperature 
may sink a degree, perhaps, and there may be some slight amelioration 
of symptoms for four-and-twenty hours, or less; after which, the 
febrile symptoms and the delirium increase with the progress of the 
eruption, and attain their maximum severity, without any particular 
change in quality, during the period of maturation. It is in such 
cases that the swelling of the face, hands and feet is greatest, that sali- 
vation is most profuse, that other symptoms referable to the mouth 
and throat are most violent, and that delirium is most continuous. [ 
There are also, in these cases, not unfrequently diarrhoea, and generally 
tremulousness, subsultus, want of control over the evacuations, and 
extreme prostration. 

After the completion of pustulation 7 and at the end of the secondary 
fever, which events are generally nearly simultaneous, a period of very 
variable duration and of very variable phenomena, during which the 
pustules dry up and disappear, supervenes. During the first three or 
four days, that is from the eighth or ninth up to the eleventh or twelfth 
day of the eruption, the pustules ooze or dry np, dark-colored, thick, 
adherent scabs form, and the skin begins to exhale a characteristic fetid 
odor, the cutaneous inflammation at the same time rapidly subsiding. 
The separation of the scabs takes place usually during the third week 
of the disease; but the healing of all the sores may not be completed 
for a week or two more, being preceded by the formation and detach- 
ment of successive crops of scabs. If the case be going on favorably, 
the febrile symptoms rapidly subside, the functions of the various i 
organs become restored, the appetite returns, and convalescence is estab- \> 



SMALL-POX. 



167 



lished. But it is daring this period that many of the serious complica- 
tions and sequelae of small-pox manifest themselves, and delay the 
patient's recovery, or carry him off. These are most frequent after 
confluent small-pox, but may supervene on the milder forms. The 
following list comprises the chief of thern. During the third or fourth 
week, boils are apt to appear on different parts of the surface; and 
then, though more generally later, subcutaneous and even deepseated 
abscesses often form rapidly, attain a large size, and are long in healing. 
Erysipelas, more especially of the face and head, is not uncommon; 
and gangrene, or pyaemia, is occasionally observed. Pustules occasion- 
ally appear on the conjunctiva; and from these or other causes oph- 
thalmia is apt to ensue, which may be suppurative and end in ulceration 
or sloughing and perforation of the cornea. Otitis is sometimes ob- 
served. Of internal complications, the most serious are suppurative 
pleurisy, pneumonia, and bronchitis. Inflammation or oedema of the 
larynx may also be fatal about this time; but this event is chiefly 
dangerous during the period of secondary fever. 

The eruption of small-pox generally leads to more or less destruction 
of the cutis vera, and to the formation of indelible cicatrices. In some 
cases (especially of the discrete variety) a few scattered pits only may 
ensue. But in the confluent disease, the destruction, especially on the 
face, may be most extensive, and the patient may become pitted, 
seamed, and scarred in all directions. 

The description of small-pox just given is so full that we shall now, 
instead of discussing at length the groups of symptoms referable to the 
various systems and organs, merely supplement it by adding certain 
details, which have either been omitted from it, or only slightly touched 
upon, or are of special importance. 

The temperature, during the stage of invasion, usually rises rapidly 
to 104°, or even as high as 106.5°; during the early period of erup- 
tion, it falls several degrees, but usually remains distinctly febrile; at 
the period of maturation, the temperature again rises, in mild cases to 
102° or 103°, in more severe cases to 104°, and when a fatal result 
threatens to 107°, or even beyond this. 

The pulse is quickened, especially during the periods of primary and 
secondary fever, but otherwise presents no special peculiarity. The 
respirations are also accelerated in relation to the amount of febrile dis- 
turbance, and, under conditions of great prostration and danger, be- 
come shallow and suspirious. Vomiting is a characteristic symptom of 
the period of invasion, and anorexia with thirst, of the whole duration 
of the malady. In adults the bowels are generally constipated; and 
the -occurrence of diarrhoea during the development of the rash is an 
unfavorable symptom. In children, however, diarrhoea is a common, 
and on the whole a favorable sign, both in the period of invasion and 
subsequently. Salivation is almost invariable in confluent cases; com- 
paratively rare and ill-marked in mild cases. 

The urine presents the ordinary febrile characters; and in some cases 
(about one-third of the total number) contains albumen, with casts and 
occasionally blood-corpuscles. Albuminuria appears early in the dis- 
ease and may continue to the end ; but it rarely, if ever, leads to per- 



168 



SPECIFIC FEBRILE DISEASES. 



manent renal disease or to anasarca. According to Mr. Marson, sup- 
pression never occurs. Inflammation of the ovary or the testicle is 
occasionally observed during the eruptive stage. Perspirations are usual 
in discrete variola from the beginning of the disease up to its termina- 
tion; but they are generally absent in confluent cases, and are not com- 
mon in children. According to the older authors, and according to 
Trousseau also, the swelling of the hands and feet which takes place in 
confluent small-pox during the period of maturation is a favorable 
sign. 

The invasion-period, in children, is often marked by drowsiness ; and 
coma and convulsions are not unfrequent • in adults, there is more or 
less giddiness and dulness ; and convulsions occasionally supervene 
even in them ; there is also frequently, and especially in severe cases, 
delirium, which may be maniacal, busy, or muttering. In confluent 
cases, the delirium may continue during the early period of efflores- 
cence ; and it generally reappears or becomes more severe at the time 
of the secondary fever. At this time, too, the patient is liable to out- 
breaks of violent mania. Treinulousness of muscles, subsultus, and 
picking at the bed-clothes, occur in the worst cases. The pain in the 
back, which is so characteristic of the onset of the disease, appears to 
be spinal, and is often associated with temporary paraplegia and loss of 
control over the bladder and rectum. 

Many varieties of small-pox have been enumerated. Exceedingly 
mild cases are sometimes observed in which the period of invasion is 
well-marked, but in which no appearance of rash follows, or a few 
scattered pocks only are discovered on the cutaneous surface or on the 
mucous membrane. Other exceptionally mild cases are met with, in 
which the disease begins with all the symptoms that usher in a well- 
marked attack of the disease ; in which the pocks appear numerous 
yet discrete; but in which, at the period when suppuration should take 
place, the vesicles dry up. In both of these cases there is no secondary 
fever, and the patient rapidly convalesces. The most important forms 
of natural small-pox, however, are those which are known respectively 
by the names of discrete, confluent, and malignant smallpox. In the 
discrete form the invasion-phenomena are generally well-pronounced ; 
but the subsidence of febrile symptoms on the first appearance of the 
rash, and their abeyance until the commencement of suppuration, are 
constant ; the secondary fever, too, is generally slight ; and the patient 
for the most part recovers without any complication. Nevertheless, in 
discrete small-pox there is some danger of death on the eighth or ninth 
day of the disease, from the sudden accession of cerebral symptoms, 
especially of coma. In the confluent variety, the symptoms are at: all 
stages far more severe that in the discrete form ; especially, there is 
little and very temporary remission of febrile symptoms ; and, more- 
over, phenomena which are rare or absent in the latter, and have al- 
ready been considered, assume considerable prominence here. It is in 
this variety, too, that complications and sequelae are specially liable to 
come on. Death from confluent small-pox is most apt to occur from 
the tenth to the fifteenth day of the disease, resulting then for the most 
part from a combination of coma and asthenia. Death may, however, 



SMALL - POX. 



169 



also occur during the next month or two from one or other of the se- 
quelae. Malignant small-pox is characterized especially by the early 
appearance of petechia? and vibices, by hemorrhagic effusion into the 
pocks, by discharges of blood from the various mucous orifices, and 
by rapid collapse. The symptoms of invasion are usually intense, the 
patient looks from the first as if struck down by a mortal disease, and 
often dies on the fourth or fifth day, or before the eruption has had 
time to become well developed. There may be delirium ; but the pa- 
tient often remains conscious to the last. 

Small-pox occurring after vaccination is generally modified in char- 
acter and is termed modified small-pox, or sometimes and inappro- 
priately varioloid. It commences with all the usual symptoms of small- 
pox, and may assume the characters of the discrete, confluent, or even 
malignant forms ; but, about the time when the tissues around the pus- 
tules should inflame and swell and secondary fever be established, the 
eruption begins to dry up, and the febrile symptoms fail to appear, or 
are very slight and transient. Trousseau says that delirium is more 
common in modified than in natural small-pox, but is less serious ; and 
that salivation rarely occurs in the modified confluent affection. It 
need scarcely be added that the degree of modification varies ; that the 
attacks, though generally benign, are sometimes serious; and, further, 
that those occurring, even after successful vaccination, sometimes do 
not deviate appreciably from the natural disease. 

Small-pox, as modified by vaccination, is for the most part a mild 
disease, and rarely fatal. Natural small-pox, on the other hand, is fatal 
in a very high degree. The statistics of the Small-Pox Hospital for 
twenty years show that of those patients who had previously been vac- 
cinated the mortality was at the rate of 6.56 per cent.; and that of 
those who had "good vaccine cicatrices 2.52 per cent, only died. It 
is very different, however, as regards unmodified small-pox, which 
destroyed 37 per cent., or more than one-third of the total number 
attacked. Discrete small-pox was attended with a mortality of 4 per 
cent., semi-confluent with a mortality of 8 per cent., and confluent 
with a mortality of no less than 50 per cent. Statistics from the same 
hospital show that the mortality among patients under five years of age 
was 50 per cent., and among those upwards of thirty still higher. The 
lowest rate of mortality was between five and tw T enty. According to 
Trousseau, children under one year never recover from small-pox, 
those between one and two rarely. Mr. Marson states that persons 
above sixty almost invariably succumb. Pregnant women usually 
abort and die. They do however occasionally recover, whether abor- 
tion takes place or not. 

Morbid Anatomy. — The post-mortem examination of small-pox cases 
reveals but little beyond what has been already described. In most 
cases the blood is dark and imperfectly coagulated ; although, in the 
ventricles of the heart fibrinous clots may be discovered. In the ma- 
lignant form of the disease, extravasations of blood may be found be- 
neath all the serous and mucous surfaces. The heart is generally flabby, 
the liver pale and soft, and the spleen more or less pulpy. The tongue 
• presents a thick fur, which may be detached at the edges and elsewhere 



170 



SPECIFIC FEBRILE DISEASES. 



in patches. And the palate, fauces, nasal fossse, larynx, trachea, and 
bronchial tubes, and sometimes the oesophagus as well, may be found 
more or less deeply congested, and covered with a granular film due to 
increase or softening of the epithelial layer; or may present, associated 
with such a formation, numerous excoriations which from their size 
and distribution are certainly suggestive of their origin in the small- 
pox rash. Under such circumstances, the bronchial tubes are loaded 
with muco-purulent fluid, and the lungs are congested and cedematous, 
and possibly pneumonic. As regards the skin-eruption, we may here 
add a few details which were out of place in a clinical account of the 
disease. The papules are due, in the first instance, partly to punctiform 
hyperemia of the cutis, over which the epidermic cells, and more espe- 
cially those of the superficial portion of the rete mucosum, become 
swollen. By degrees, serous fluid is poured out into the substance of 
the affected epidermis, raising the horny layer from the swollen group 
of cells below, but detaching it imperfectly so that a number of small 
irregular intercommunicating serous cavities are produced. But soon 
suppuration occurs in the subjacent rete mucosum, and the pus-corpus- 
cles then rapidly diffuse themselves, and the pock is converted into a 
pustule. The umbilicated character which is so common is due to the 
presence either of a hair or of a sudoriparous gland, the connection of 
which with the subjacent true skin has not yet been destroyed. The 
suppurative process need not implicate the true skin below ; but not 
unfrequently it involves and destroys it to a greater or less depth, and 
is prolonged inwards along the hairs or glands. Under the former 
circumstances the pustule leaves no permanent trace; under the latter 
a depressed cicatrix results presenting numerous pits upon its surface. 

Treatment. — In the mildest forms of small-pox medicinal treatment 
is scarcely called for ; in the severest it is useless ; and indeed, under 
any circumstances, has but little influence over the course of the disease. 
The patient should be placed in an airy chamber, which should be well 
ventilated, and kept at a uniform and medium temperature. He may 
take as medicine some cooling drink — lemonade, soda-water, or other 
saline or acidulated solution. If the bowels are confined they may be 
acted upon by some mild laxative; if there be diarrhoea (especially in 
adults), they must be restrained by opium, or other astringents. The 
soreness of the throat may be relieved by warm bland drinks, or black- 
currant jelly ; and, if there be much discharge from the nose and about 
the fauces, these parts may be washed with some mild detergent or as- 
tringent solution. Opium is often of value both in relieving the de- 
lirium and assuaging the pain of the invasion-period; and especially 
useful during the period of secondary fever. If there be great tendency 
to collapse, ammonia may be serviceable. Nourishment should be 
regularly administered, and should consist of the materials generally 
suitable for febrile conditions, namely, milk, rice-water, gruel, beef tea, 
and such-like. Alcoholic stimulants must be given according to cir- 
cumstances ; but are especially important in the malignant form of 
the disease, and in the later periods of confluent small-pox, or when- 
ever there is tendency to collapse. As to local treatment, the patient 
should be kept clean, and frequently sponged with tepid water ; and, 



COW-POX — VACCINATION. 171 

as the eruption reaches its height, and in its decline, the eyes and vari- 
ous mucous orifices need especial care. They should be sponged, and 
dried, and anointed with olive oil; and if there be any tendency to 
conjunctival inflammation and ulceration, weak solutions of nitrate of 
silver or sulphate of zinc should be occasionally dropped in. Various 
plans have been suggested and employed to prevent pitting ; but it is 
questionable if any is really efficacious. It has been recommended, to 
puncture the pustules, to wash away their contents, and then to insert 
into each a fine point of nitrate of silver. If this be done, it should be 
done when the pocks first distinctly contain fluid ; but the plan is 
scarcely applicable to the cases in which the prevention of pitting is 
most needed, namely, confluent cases. The local application of strong 
carbolic acid has also been recommended. It is probably best, gen- 
erally, to anoint the surface with sweet oil, carbolized. During the 
period of decline of the eruption, and that of convalescence, the strength 
of the patient needs to be supported in every way, by good diet, by 
stimulants, and by quinine or other tonics. The various complications 
of small-pox must be treated according to ordinary principles, bearing 
in mind, however, that their presence as a rule enfeebles the patient, 
and is therefore an indication for sustaining; strength. 

The most important treatment, however, of small-pox is prevention 
by inoculation of the small-pox virus, or of that of cow-pox. The 
former plan has fallen into disuse, and indeed is penal in this country, 
yet nevertheless under certain conditions may be worthy of revival. 
The inoculated small-pox is a much milder disease than that obtained 
in the usual way ; and, according to Dr. Gregory's analysis of the 
records of the Small-Pox and Inoculation Hospital of London, from 
the year 1746 to 1822, the deaths from it were at the rate of three only 
in a thousand. The mildness of the inoculated disease appears to be 
enhanced by using for inoculation the virus from a mild case, and by 
repeated selection for that purpose of inoculated cases. It may be 
further enhanced by inoculating those only who are at the age at which 
small-pox is least dangerous to life. The virus should be taken from 
a pock which has not yet commenced to suppurate; and the operation 
of inoculation should be performed exactly like that of vaccination. 
! Our remarks on vaccination will be given in the next article. 



COW-POX. (Vaccinia.) VACCINATION. 

i 

Definition. — Cow-pox is a specific contagious disease of cattle, char- 
i acterized by the local development of pustules (almost exactly resem- 
j bling in their progress and results the pocks of variola) prevailing at 
| times epidemically among cattle, and communicable from them to man 
| and other animals by inoculation. 

Causation and Relations with Small-pox. — Cow-pox is essentially a 
disease of cattle ; and among them it has been found to prevail epidemi- 
. cally at times in every country in Europe. Yet, although thus common, 

1 w- 



172 



SPECIFIC FEBRILE DISEASES. 



it is doubtful if it is communicable from animal to animal either by the 
breath or by the secretions. It is certain, however, that it is eminently 
contagious by inoculation from its specific pocks. And it is probably 
by this means that its spread is mainly, if not wholly, effected. Like 
most other affections originating in a specific contagium, cow-pox by 
one attack gives immunity against future attacks; but it similarly 
affords immunity against attacks of small-pox. It is this latter fact 
which gives so great an interest to all questions relating to its intimate 
pathology, and especially to the question of its exact relations with 
small-pox. Its identity with this latter disease was early surmised ; 
and many arguments, in addition to the fact that it is protective 
against it, have been adduced in favor of this view. Thus, there is 
scarcely any appreciable difference between the pocks of the two affec- 
tions, either in their anatomical characters or in their progress ; it has 
been over and over again stated that epidemics of small-pox and of 
cow-pox occur in relation with one another; and, again, many experi- 
ments are adduced, which are supposed to prove, 1st, that small-pox 
may be imparted either by inoculation or by fomites to cows, and that 
in them it assumes all the characters of cow-pox ; and 2d, that vaccina- 
tion has been effectually performed, both on human beings and on cows, 
from the pocks of the vaccine small-pox thus produced — the reinocu- 
lated disease thenceforward assuming all the characters of genuine cow- 
pox. On the other hand, Chauveau's comparatively recent and appar- 
ently quite trustworthy investigations show clearly that small-pox is 
inoculable with difficulty in cattle; that in them it produces merely a 
few abortive papules at the seat of inoculation, unattended with obvious 
constitutional symptoms; and that by reinoculating susceptible human 
beings with the fluid obtained from these papules, the disease which 
they acquire is in no sense cow-pox, but true variola ; that variolous 
inoculation indeed, whether in the cow T or in man, produces variola 
alone, and never a disease which is convertible into, or admits of being 
confounded with cow-pox. It seems to us clear, therefore, that although 
cow-pox has in many respects a very close affinity with small-pox, it 
is essentially distinct from it, and must be regarded as a disease mi 
generis. 

Symptoms and Progress in Cattle. — Natural cow-pox affects chiefly 
the udders and teats of cows, and is indicated in them by the develop- 
ment of a number of pustules which individually run through all the 
stages characterizing the small-pox pustule. They begin as papules, 
in a few days become vesicular, and by the seventh, eighth, or ninth 
day attain their full development, measuring then from J inch to f 
inch in diameter. From that date their contents become purulent, 
and a congested areola, with much subcutaneous induration and thick- 
ening, forms. A thick dark adherent scab is developed by about the 
thirteenth or fourteenth day, which becomes detached in the course of 
the following week, leaving a depressed cicatrix. The febrile symp- 
toms which attend the progress of the disease are very slight, and for 
the most part of no importance ; generally, moreover, the local affec- 
tion is quite free from untoward complications. When cow-pox is 
given by inoculation, the papules as a rule first make their appearance 



COW-POX — VACCINATION. 173 

at the end of three days ; occasionally, however, on the second or the 
fourth day. 

Symptoms and Progress in Man. — Cow-pox as it affects the human 
subject differs but little from the same disease in cows. No specific 
change is observable at the point of inoculation until the end of the 
second day, or until the third day, when a small congested papule 
makes its appearance. This gradually increases in size, and on the 
fifth or sixth day has become a circular grayish vesicle, with a some- 
what depressed centre. By the eighth day it has attained its full 
development, forms then a well-marked grayish prominent vesicle 
with a flat or cupped surface, and containing in its interior a colorless 
transparent viscid fluid. On the eighth or ninth day the contents of 
the vesicle begin to get purulent, a red areola forms and some thick- 
ening and induration of the inflamed area take place. These phe- 
nomena increase during the next two days; the induration and thick- 
ening become greater and more extensive, the areola attains a diameter 
of from one to three inches, the pock itself undergoes some little exten- 
sion, and its contents become wholly converted into pus. After the 
tenth or eleventh day a change takes place ; the pustule begins to dry 
up, and the areola and other signs of inflammation to subside. By 
the fourteenth or fifteenth day a hard dark-colored scab has formed, 
which contracts and blackens, and falls off from the twentieth to the 
twenty-fifth day, leaving a depressed pitted scar \v T hich remains per- 
manently. 

The vaccinated patient does not usually present general symptoms 
or complications until about the eighth day, and during the two or 
three days immediately following. There is then generally some feb- 
rile disturbance, with restlessness and irritability and slight derangement 
of the digestive organs ; the glands next above the seat of operation 
generally become enlarged and painful ; and sometimes a roseolous 
eruption spreads over the vaccinated limb, and involves, maybe, other 
parts of the body. This eruption is sometimes vesicular or papular. 

When vaccination is performed directly from the cow, the progress 
of the eruption is generally somewhat retarded ; and the local and 
general symptoms are all more severe than when humanized lymph is 
employed. 

In cases of revaccination one of thre^ results may follow : either (if 
the patient be fully protected) the revaccination has no effect beyond, it 
may be, a little local irritation due to the lancet puncture and the 
introduction of irritant matter; or (if all protection has ceased) the 
operation is followed by the development of the typical pock ; or (if 
there be simply impairment of protection) the results of the operation 
are modified. In the last case, the local effect comes on early, the 
papule (which may remain a papule or become an acuminated vesicle) 
attains its full development on the fifth or sixth day, and immediately 
after forms a scab which falls off in the course of a day or two. There 
is generally, however, a good deal of attendant local and constitutional 
irritation ; much more, in fact, than occurs in the course of primary 
vaccination. 

Other circumstances besides those which have been considered 



174 



SPECIFIC FEBRILE DISEASES. 



occasionally modify the results of vaccination ; among them, the age of 
the pock from which the lymph has been taken, and the health of the 
patient operated upon. 

It must not be forgotten that cow-pox, whether in the cow or in 
man, is not comprised within its local manifestations; but that it is 
(however mild its attack may be) a disease involving the whole organ- 
ism, as is proved by the marvellous influence which one attack has in 
protecting the body from subsequent attacks both of cow-pox and of 
small-pox, by whatever route and in whatever manner they may be 
introduced. Guided by what we know of inoculated small-pox — 
namely, that at the seat of inoculation a papule appears, which grad- 
ually becomes a well-developed pock; that this is simply a local 
affection, which is followed about the eighth day by feverishness and 
other symptoms of invasion, which are themselves succeeded in two or 
three days more by the general eruption of small-pox — it seems obvious 
to assume that the pustules of cow-pox which appear on the udders of 
cows, and those which result from vaccination on the arms of men, are 
simply, as they appear to be, local affections on which the true general- 
ized disease (in this case abortive and altogether trivial in its symptoms) 
supervenes at about the period of maturation ; in other words, that the 
period which elapses between inoculation and full development of the 
pock corresponds strictly to the latent period of other exanthems. 

Protective Influence of Vaccination against Small-Pox. — A belief in 
the protective influence of cow-pox against variola seems to have been 
commonly entertained in Gloucestershire, during the latter half of the 
eighteenth century. And a similar belief appears to have prevailed, 
during the same period, in some parts of Germany. It is said, indeed, 
that a schoolmaster named Plett, in Holstein, vaccinated two children 
in the year 1771 ; and it seems to be established that an English 
farmer, named Benjamin Jesty, performed the same operation on his 
wife and tw T o sons in the year 1774. The value of vaccination was, 
however, first established on a solid basis by the scientific investigations 
of Edward Jenner, whose attention was directed to the subject while 
he was yet an apprentice, and whose first publication in reference to it 
appeared in the year 1798. We need not pursue in detail the history 
of vaccination further. It is sufficient to say that its practice has been 
adopted since then throughout the whole civilized world ; that the 
claim, which Jenner originally made for it — namely, that it is as pro- 
tective against subsequent attacks of small-pox as an attack of small- 
pox itself is, and neither more nor less so — has been verified by universal 
experience; that experience and experiment have alike shown, that its 
protective influence is in no degree diminished by its continued trans- 
mission from man to man ; and, lastly, that small-pox has died out or 
diminished in severity, in exact proportion as efficient vaccination has 
been generalized. It is certain, indeed, that thorough vaccinal inocu- 
lation confers in most cases absolute exemption for life; but that in 
some cases the protective influence diminishes in the course of years, 
so that if the patient contracts small-pox he has it in a modified and 
mild form ; and that where small-pox has been rife, or epidemics have 
prevailed, the uirwonted occurrence of the disease has been distinctly 



COW-POX — VACCINATION. 



175 



traced to neglect of vaccination, or to imperfect vaccination, or both. 
Mr. Marson's tabulated results of the experience at the Small-Pox 
Hospital, during twenty years, show at a glance the accuracy of the 
above statements : 

Number Mortality 
Patients admitted with small-pox. admitted. per cent. 

1. Having one vaccine cicatrix, .... 2001 7.73 

2. " two » «• ..... 1446 4.70 

3. ' : three " " .... 518 1.95 

4. " four or more " . . . . 544 0.55 

5. Stated to have been vaccinated, but having 

no cicatrix, ..... 



370 23 57 



It will be recollected that the mortality of primary small-pox is shown, 
by the same authority, to be 37 per cent. 

Dangers of Vaccination. — The only valid objection to vaccination is 
that it may, and does occasionally, induce or introduce maladies which 
the patient would otherwise have escaped. We do not here refer to 
the immediate accidental results of vaccination, such as erysipelas and 
pyemia, which may equally follow on a mere prick or the simplest 
scratch ; but to certain constitutional disorders, such as scrofula and 
syphilis, which have been attributed to it. There is no doubt that 
syphilis has been thus imparted ; but the recorded cases are very few, 
and these have been the result of gross carelessness or ignorance ; for 
there is no reason to believe that a vaccinated child, who presents no 
visible indications of syphilis, could impart that disease, and but little 
even to believe that the pure lymph of a distinctly syphilitic child is 
charged with the syphilitic virus. [Mr. Jonathan Hutchinson's in- 
vestigations have, nevertheless, led him to form a very different 
opinion on this point. In the cases that have come under his observa- 
tion, the children, from whom the lymph used in vaccination was 
taken, so far from presenting a puny or sickly aspect, wer» selected for 
this purpose on account of their apparently excellent health. Nor did 
a minute examination in every instance enable him to detect positive 
evidences of syphilis. While admitting that the pure lymph of vaccine 
vesicle is probably never the vehicle by which the disease is communi- 
cated, he says there is not the least evidence, in three of the four series 
of cases which he has recorded, that the lymph used was visibly con- 
taminated with blood. It appears to be sufficient to allow the vesicle 
to draw or weep. With this drainage, he thinks, corpuscular elements 
of the blood and tissues become free. In America, where the crusts 
are almost exclusively used, it can rarely be positively ascertained 
whether or not blood, or some product of the tissues, has become mixed 
with the lymph. It is therefore absolutely essential, before using a 
crust, to know that the child, who has furnished it, is entirely free from 
disease. Inasmuch, however, as vaccination, in spite of the exercise 
of a reasonable degree of care, has occasionally been the means by 
which syphilis has been inoculated, common prudence would suggest 
as frequent a recourse to lymph obtained directly from the cow as 
possible.] As regards scrofula, the only ground for the belief in its 
inoculability by vaccination is the circumstance that lichen, eczema, 
and impetigo — affections which are common in children, especially 



176 



SPECIFIC FEBRILE DISEASES. 



about the period of teething, and which are by some erroneously re- 
garded as scrofulous — occasionally supervene on vaccination, as they 
do on other forms of local irritation. 

Performance of Vaccination. — The operation of vaccination should 
be performed at as early a period of life as possible, especially if small- 
pox has been in any degree prevalent. It is now required by law that 
a child shall be vacciuated within three months of birth. It is desira- 
ble that it should be in good health, and free from skin disease. In 
order to obviate the tendency which the vaccinal influence has to die 
out, it is now almost universally admitted that the operation should be 
repeated about the period of puberty. And further, it is always im- 
portant in the case of persons who are, or are liable to be, exposed to 
small-pox (if they have only imperfect vaccinal marks and have not 
been successfully revaccinated) that the operation should be at once re- 
peated. It should, however, be borne in mind that vaccination has no 
modifying effect on small-pox which has been previously contracted, 
unless it be so timed that the maturation of the vaccine vesicle shall 
precede the period of the variolous invasion. Thus, since the primary 
vaccine vesicle attains its full development on the ninth or tenth day, 
and since the latent period of small-pox is usually twelve days, primary 
vaccination, to have any beneficial effect, should be performed certainly 
not later than the second or third day after exposure to the variolous 
contagion. The vesicle, however, which follows revaccination attains 
its maximum on the seventh or eighth day; so that, if the patient has 
been previously vaccinated, the operation may possibly be beneficially 
performed as late as the fourth or fifth day after exposure. 

The lymph for vaccination should never be taken from persons who 1 
are diseased, or in whom there is any suspicion of syphilis or of other 
infectious disorder; nor from pocks which are ill-developed or puru- 
lent ; nor from those which are the product of revaccination. Good 
vaccine lymph is yielded by normal pocks from the fourth or fifth to 
the eighth day after inoculation. That of a later date should never be 
employed. As a rule the lymph is taken on the eighth day. The 
vesicles should be freely punctured with the point of a lancet, care 
beino- taken to avoid haemorrhage ; and the fluid which exudes should 
then at once be employed for vaccination, or should be preserved on 
ivory points which may be dipped into it, or between glasses, or pref- 
erably in capillary glass tubes. No squeezing of the vesicle should be 
had recourse to; but if, after all the lymph which first flows has been 
used, the surface be gently wiped, a fresh exudation of good lymph 
usually takes place. Lymph may also be diluted with glycerin and 
thus preserved — a method of special value when lymph is scarce. 

Vaccination is generally, and certainly most conveniently, performed 
on the upper and outer part of the upper arm. There, five distinct 
punctures should be made at J or f inch distance from one another. 
Various modes of performing the operation are recommended. The 
simplest is to make with a sharp, clean, well-charged lancet, in the 
stretched skin, a valvular puncture directed from above downwards, 
and sufficiently deep to wound the vessels of the cutis. A second method, 
of which there are numerous modifications, is to make groups of parallel 



CHICKEN-POX. 



177 



or crossed scratches or of fine punctures, so as to allow of a little oozing 
I of blood, and then having wiped the blood away to anoint the surface 
with the vaccine lymph. If the groups be small they should be five 
in number; if large three will suffice. If the lymph which is employed 
be fresh, or has been preserved in capillary tubes, it may be at once 
applied on the point of the lancet; but if it has been preserved in the 
dry condition, it is essential that it be first moistened thoroughly with 
a small quantity of water. If no result whatever follow the operation, 
| whether it be in a case of primary vaccination or one of revaccination, 
either the lymph employed is inefficient, or the operation has been im- 
perfectly performed, or (which is less probable) the patient is insuscep- 
tible. Under any circumstances, the operation shouid be repeated until 
a definite local result of some kind or other is obtained. 



CHICKEN-POX. ( Varicella.) 

Definition. — A specific contagious disorder, characterized by the ap- 
pearance of vesicles in successive crops, which in the course of two or 
three days form scabs. 

Causation. — Varicella has been largely confounded with small-pox, 
I of which it lias been regarded as a modified variety. This view is still 
i entertained by Hebra and some other writers. Of the perfect distinc- 
tion, however, between them there can be no doubt; for the one dis- 
ease is not protective against the other, although each is protective 
agonist its own future attacks ; the one disease never imparts the other; 
and they occur in independent epidemics. Chicken-pox is contagious 
in a very high degree, and spreads both by means of the air and through 
the medium of fomites. It is doubtful whether it has been hitherto 
imparted by inoculation. It occurs epidemically; but its epidemics 
seem to be neither so frequent nor so widespread as those of measles, 
hooping-cough, and scarlet fever. It mainly attacks children, yet adults 
are by no means exempt. 

Symptoms and Progress. — The period of incubation is somewhat 
uncertain. According to different authors, it varies between four or 
five and sixteen or seventeen days. In some cases this stage is of 
exactly a week's duration. But more commonly perhaps it lasts a 
fortnight. The invasion is marked by febrile symptoms which are 
S occasionally severe but present no distinctive character, and which, 
j generally in a few hours, at all events before the completion of twenty- 
I four, are followed by the appearance of the rash. This consists in the 
; first instance of a number of rosy papules, not unlike the spots of 
i typhoid fever, appearing singly, or in groups of two or three, on 
| various parts of the body — head, face, trunk, limbs — but most cora- 
| monly, perhaps, first upon the chest. These in the course of the next 
' clay or two, or even after a few hours, become distinct vesicles, contain- 
| ing a transparent fluid, and surrounded usually by a more or less 
. distinct inflammatory halo. The vesicles are at first small and rounded 

12 

i 



178 



SPECIFIC FEBRILE DISEASES. 



or acuminated, then for a day or two increase in size, becoming some- 
times as large as a split pea, occasionally irregular in form, and often 
umbilicated ; their contents at the same time become milky. They 
then rupture or dry up, and small dark-colored adherent scabs result. 
The formation of the scabs is completed at the end of four or five days 
or a week from the first sign of illness ; and these may remain adherent 
for two or three days or even a week longer, when they separate, leav- 
ing red stains which are slow to disappear, and not unfrequently per- 
manent depressed cicatrices. The eruption, however, is not limited to 
the generally scanty crop which first appears. But during the first 
three or four days of the disease fresh crops of papules in largely in- 
creased numbers, and irregularly distributed, make their appearance 
day by day ; and these papules go through the same stages as those 
which w T ere first developed. During the progress of the disease vesicles 
with inflamed areolae generally appear, in small numbers, on the palate, 
sides of the tongue, and mucous surface of the lips and cheeks. 

The general symptoms of varicella are for the most part slight and 
unimportant. There is commonly some feverishness, languor, and loss 
of appetite ; and the fever is liable to nocturnal exacerbations during 
the maturation of the vesicles. The temperature often rises to 101°, 
but in some cases may reach 104°. The tongue probably remains 
cleau throughout. Occasionally, however, the symptoms are much 
more severe, though never probably so severe as to excite alarm. 
Death rarely if ever results. 

The malady attains its height' usually in a week or ten days, and 
runs its course in ten days or a fortnight. The complications and 
sequelae are unimportant; nevertheless, children often remain weak 
and out of health for some time after an attack. 

Treatment — The patient should be separated from those who are 
liable to take the disease, and confined to his room if not to bed. He 
should be prevented, if possible, from scratching his pimples, those at 
least upon the face, in order to diminish the liability to pit. No fur- 
ther special treatment is necessary. 



TYPHUS. 

Definition. — A highly contagious fever, lasting from two to three 
weeks, and attended with a characteristic measly eruption coming out 
from the fourth to the seventh day. 

Causation and History. — Typhus fever seems to be a disease of tem- 
perate climates especially. No European country is free from its occa- 
sional epidemic prevalence ; but from Ireland it is probably never 
entirely absent; and indeed Great Britain and Ireland may be regarded 
as its headquarters. Epidemics have occurred in the United States 
and in Canada. There is even now some doubt as to whether it has 
ever been observed in India ; but, excepting this doubtful case, it is 
quite unknown in tropical countries. It has been introduced into, but 



TYPHUS. 



179 



has not spread in, Australia and New Zealand. Typhus appears, for 
the most part, in casual outbreaks which assume an epidemic character, 
spread widely, and after lasting for months or years subside and die 
out. Almost all recorded epidemics seem to have been satisfactorily 
traced to long-continued overcrowding, in association with defective 
ventilation and personal filth. With these conditions starvation is no 
doubt to a large extent often combined. But starvation alone, such as 
results from famine or from widespread want (from whatever cause) of 
the necessaries of life, leads rather to the development of relapsing fever 
than of typhus; while, on the other hand, typhus has not uufrequently 
become epidemic where there has been no starvation, but where the 
other conditions which have been enumerated have prevailed in a 
marked degree. Epidemics of typhus have originated mainly in the 
overcrowded parts of great cities, in seasons of distress and want and of 
consequent exceptional overcrowding; in armies, under equivalent con- 
ditions; and in prisons. There can be no doubt, indeed, that over- 
crowding and bad ventilation are most effective agents in concentrating 
the typhus poison, and in promoting the spread of the disease; and it 
may be added that everything which depresses either the body or. the 
mind — want of food, fatigue, intoxication, fear, or anxiety, and perhaps 
even the debility which follows various diseases — must be regarded as a 
predisposing cause. In all the countries in which typhus chiefly occurs, 
season and weather appear to exert no direct influence over either its 
origin or its spread. All ages are liable to its attacks, although it 
appears from statistics that it is most common between fifteen and 
twenty-five ; and males and females suffer from it in nearly equal pro- 
portion. One attack confers almost complete immunity against sub- 
sequent attacks ; yet, occasionally, two and even three seizures have 
been observed in the same individual. Excepting those who have thus 
acquired protection, every one is liable to take typhus. It is true that 
some unprotected persons, even when exposed daily to the influence of 
the disease, fail to contract it for weeks, months, it may be years; but 
many cases are on record where such persons have been attacked with 
it at last and have then succumbed to their attack. 

That typhus is a highly contagious disease is established by over- 
whelming evidence. Its poison is carried by the atmosphere, and is 
absorbed and retained in a potent condition for a considerable time by 
fomites. But it presents certain marked peculiarities of behavior ex- 
ternal to the system ; thus it clings, as it were, around the body of the 
patient, and seems to be rapidly destroyed by diffusion through the 
atmosphere ; so that while its operation is intense under appropriate 
conditions of overcrowding and bad ventilation, it becomes almost nil 
under opposite circumstances ; and hence, the disease rarely spreads 
(excepting to the immediate attendants) in the wards of a well-arranged 
hospital, or among the households of the middle and upper classes. 
] The contagium of typhus is probably exhaled with the breath and from 
| the general surface. It is doubtful, however, whether the other ex- 
cretions are infective, and whether the disease can be imparted by the 
dead body. Both the breath and the perspiration of typhus patients 
' yield a characteristic offensive odor, and there is reason to believe that 



180 



SPECIFIC FEBRILE DISEASES. 



the contagiousness of a case has some direct proportion to its smell. 
Dr. Murchison considers that the disease is most contagious from the 
end of the first week up to convalescence. The contagium is inhaled 
with the breath and enters the system, therefore, by the mucous sur- 
face of the nose, mouth, fauces, or respiratory tract. 

Although it is now admitted by all the best observers that typhus 
when once it has made its appearance is eminently contagious ; it is 
still a moot question whether typhus epidemics owe their origin to new 
developments of the typhus poison, or whether they are due to the 
presence in a latent form of the contagium, which is rendered operative 
by the concurrence of suitable conditions. The former view is strongly 
advocated by Dr. Murchison. His arguments, however, though forci- 
ble are not conclusive; and we must confess that the latter view seems i 
to us infinitely more consonant than his with the analogies afforded by 
the exanthemata, and with the present state of pathological knowledge. 

Symptoms and Progress. — The latent period of typhus appears to be 
of very uncertain duration. Cases are recorded in which the symp- 
toms of invasion manifested themselves almost immediately after ex- 
posure to the concentrated poison ; on the other hand, the primary 
symptoms have in some cases failed to appear until after the lapse of 
twenty-one days, or even more. The usual period varies probably be- 
tween five or six and twelve or fourteen days. The invasion is occa- 
sionally heralded by an ill-defined sense of poorliness lasting for a day 
or two, at the end of which time, or much more commonly without 
any such warning, the initial symptoms manifest themselves. These 
consist generally in a sense of chilliness or slight rigors, pain in the 
forehead and back, soreness in the thighs and other fleshy portions of 
the limbs; with which are associated before long, or from the com- 
mencement, increased heat of skin, occasional slight sweats, diffused 
dusky redness of face and congestion of conjunctivae, acceleration of 
pulse, furring of tongue, anorexia and thirst, scanty and high-colored 
urine, muscular weakness, lassitude, giddiness, and loss of sleep, or 
disturbed sleep with tendency to dream. Occasionally there is some j 
nausea or even sickness, and generally the bowels are constipated. 
For the first two or three days, notwithstanding gradual aggravation 
of the symptoms, the patient may not feel sufficiently ill to take to his 
bed. From the third to the seventh day, generally on the fourth or 
fifth, the characteristic measly eruption makes its appearance on the 
sides of the chest and abdomen, and on the backs of the hands, wrists, 
and elbows, and in the course of a couple of days becomes general over 
the trunk, arms, and legs, and sometimes, but much more rarely, 
shows itself on the neck and face. It remains out, well developed 
but undergoing slight changes of color, for two or three days more, 
then gradually fades, and finally disappears by about the fourteenth 
day, unless it assumes a petechial form, when its disappearance is re- 
tarded. About the time when the eruption commences, or a little 
earlier, the patient has probably taken to his bed, and has begun to be 
apathetic and forgetful, to present a dull and listless expression, and to I 
ramble at night. Presently he loses his headache, becoming, however, \ 
increasingly dull, forgetful, and stupid ; and the delirium, which had ;i 



TYPHUS. 



181 



hitherto been nocturnal and limited probably to the moments between 
waking and sleeping, becomes constant. Occasionally the delirium is 
violent and maniacal, and the patient requires restraint; sometimes it 
is the busy delirium of delirium tremens; but much more commonly 
it is of the low muttering kind, known by the name of " typhomania," 
into which, indeed, the other varieties tend soon to merge. In this 
condition the patient can at first be readily recalled to himself, and will 
answer correctly and do what he is told to do. His aspect becomes 
more oppressed ; the redness of his face and eyes assumes a more dusky 
tint, as likewise does that of h:s rash; sordes begin to collect on the 
teeth, and the tongue becomes dry and brown; the respirations and 
pulse increase in frequency, and the latter becomes small, weak, some- 
times dicrotous or irregular ; the temperature falls somewhat ; the skin 
becomes clammy, the limbs tremulous; and the general debility in- 
creases rapidly. About the tenth day the typhoid symptoms of the 
disease are fully developed ; the patient has become still feebler and 
more stupid ; he lies in bed on his back with his mouth half open and 
his eyes half closed, taking no notice of what is going on around him. 
He is in a semi-comatose condition, muttering at times unintelligibly 
and incoherently, breathing sometimes more rapidly sometimes less 
rapidly than natural, and moaning or groaning probably with each 
respiratory act; his lips and teeth are coated with sordes, his tongue is 
small, hard, dry, and black; he tends to sink towards the bottom of 
the bed ; his muscles are tremulous, there is subsultus tendinum in the 
arms especially, and floccitatio, or a tendency to pick at the bedclothes ; 
his motions are passed unconsciously, and his urine is generally re- 
tained, though dribbling away perhaps from the overdistended blad- 
der; his pulse has become extremely feeble, dicrotous, or irregular; 
his temperature still probably shows a tendency to sink ; the rash fades 
or becomes replaced by petechias ; and perspirations break out. There 
is a tendency also to the formation of bed-sores. 

These symptoms continue probably for several days, the patient 
meanwhile becoming more prostrate and more comatose, and then, 
generally on or about the thirteenth or fourteenth day, either the coma 
becomes profound, the temperature rapidly rises, and the patient sinks, 
or he falls perhaps into a gentle sleep, from which, after some hours, 
he awakes sensible and convalescent, with a greatly diminished tem- 
perature and pulse, but in a condition of extreme debility. If the case 
continues to go on favorably, the tongue quickly cleans, the appetite 
returns, and restoration to perfect health ensues at the end of three or 
four weeks. 

We will now discuss some of the more important phenomena of 
, typhus seriatim. The temperature rises at once, and generally attains 
I its maximum, which rarely exceeds 106° in adults, and 107° in chil- 
j dren, between the middle and end of the first week. Exceptionally it 
j does not rise above 103°. It remains at the maximum for two or 
! three days, and then usually, between the seventh and tenth day, falls 
i slightly, continuing to fall until the period of crisis, when, according 
as death or recovery takes place, there is either a rapid rise, which 
may exceed by several degrees that previously attained, or a sudden 



182 



SPECIFIC FEBRILE DISEASES. 



fall. The diurnal variations are slight and irregular, though, on the 
whole, tending to present an evening rise and a morning fall. If a 
high temperature be maintained in the second or third week, or an 
unusual rise take place, some inflammatory complication is probably 
present. 

The eruption of typhus embraces two factors, a mere mottling of 
the surface, and the presence of distinct dusky-red spots. They are 
usually present together. The mottling, which soon becomes general, 
precedes the development of the rash, and first appears in those situa- 
tions in which the rash subsequently commences. It is due to the 
appearance of abundant, ill-defined, dusky-red spots, which are not 
elevated, disappear on pressure, and individually are scarcely percep- 
tible. The rash presents the color and very much the appearance of that 
of measles. The spots, however, are smaller, less elevated, and do not 
assume a crescentic arrangement. They are slightly elevated, round- 
ish, fading at the margins, and at first disappear under pressure. 
During the first day or two their color is comparatively bright, and 
due simply to stagnation of blood in the capillary vessels; during the 
subsequent two or three days they assume a dusky hue, the result 
probably, in some degree, of the transudation of the coloring matter 
of the blood, and then either they fade away, or hsemorrhage takes 
place into them, and they become converted into petechise. The 
typhus eruption is almost invariably present. In the year 1864, it 
was observed in the London Fever Hospital in 97.77 per cent, of the 
cases admitted. In children it is often very slight, and of short dura- 
tion, and may therefore be readily overlooked. In adults it is usually 
well developed, and generally the severity of the disease is in propor- 
tion to the abundance of the rash. The abundant formation of pete- 
chise which occurs generally towards the latter part of the second week 
is an unfavorable sign. 

The respirations are generally slightly increased in number during 
the earlier period of the disease. In the typhoid stage they may rise 
to thirty and forty in the minute. There is very often, from the be- 
ginning of the disease, a slight cough, and this may continue through- 
out the illness, or increase, and be attended with mucous expectora- 
tion, which is sometimes tinged with blood. It is traceable to the 
congestion of the bronchial tubes and lungs which so commonly attends 
typhus. 

The action of the heart is weak, and towards the latter period of the 
disease the first sound may become inaudible. The pulse is always 
feeble, and generally small, and its feebleness and smallness increase as 
the disease advances, until at length it becomes undulating, thready, 
irregular, and almost imperceptible. The rate of the pulse presents 
great variations. In adults it ranges usually between 100 and 120. 
During the first few days it rarely exceeds 100. Subsequently it rises 
in frequency, and may attain the rate of 130 or 140 or more in a 
minute. But when it exceeds 120, the danger is generally very great. 
Occasionally it falls in the second week to 40 or 50. In children the 
pulse is usually much quicker than in adults. 

Sickness is not a common feature of typhus, although it occasion- 



TYPHUS. 



183 



ally marks its onset. The bowels are generally constipated, and the 
motions normal, but occasionally diarrhoea occurs early in the disease, 
and it is by no means uncommon about the period of the crisis, when 
also it may be dysenteric. The tongue at the beginning may be abnor- 
mally red only, or even natural, but it soon becomes covered with a 
thick, whitish fur, which gradually gets yellowish, and towards the end 
of the first week brown. Later the tongue shrinks and becomes black, 
and equivalent changes take place in connection with the lips, palate, 
and fauces. 

The urine is scanty, high-colored, of high specific gravity, and acid 
during the early period of typhus, and contains an excess of urea, and 
sometimes of uric acid and of urates, which latter may be deposited. 
Later on the urine becomes paler and more abundant, and the urea 
falls considerably below the normal standard. Chlorides are deficient, 
and occasionally disappear during the pyrexial condition. Albumen 
in small quantities, accompanied sometimes with blood-corpuscles and 
granular casts, is frequently present in the urine. It is not certain at 
what date it generally appears, or when it generally ceases, nor is it a 
symptom of importance. It is most common, however, in severe cases, 
and probably commences usually on the third or fourth day. 

Pregnant women rarely miscarry ; nor does pregnancy or miscarriage 
add materially to the danger of the patient. The prematurely-born 
foetus if old enough generally survives. 

The symptoms referable to the nervous system form always a char- 
acteristic part of typhus fever. Most of these have already been con- 
sidered. The patient at first has headache with some dulness and con- 
fusion of mind (which impress themselves on his manner and on the 
expression of his features) and sleeplessness. In a few days he begins 
to wander at night between waking and sleeping, becoming in the in- 
tervals gradually more stupid and forgetful. At the end of the first 
week or before, the delirium becomes constant, still, however, worse at 
night-time; and the patient perhaps is drowsy in the day. The delir- 
ium, as has been pointed out, may vary in character, but generally 
soon lapses into typhomania. Gradually the patient becomes more and 
more unconscious ; and if the case be about to end fatally, he proba- 
bly falls into profound coma, preceded occasionally by convulsions. 
The coma sometimes assumes the character of what is termed coma- 
vigil, in which the patient lies quite unconscious with his eyes open 
and fixed. In the early part of the disease there is generally some in- 
tolerance of light and singing in the ears. At the latter part deafness 
often comes on; and if the patient be comatose the pupils contract usu- 
ally to mere points. The muscular pains of the first period, the mus- 
cular tremors which soon supervene, and the subsultus, floccitatio, and 
loss of control over the rectum and bladder of the later periods, are 
all more or less directly dependent on nervous implication. 

Typhus fever varies very much in its severity. It is sometimes so 
mild, and of such short duration, and so free from any distinctive char- 
acter, that excepting under the guidance of attendant circumstances 
correct diagnosis is impossible. In many cases, again, even where the 
fever is present in a well-marked form the typhoid stage is never 



184 



SPECIFIC FEBRILE DISEASES. 



developed ; but somewhere between the seventh and tenth day, when 
usually the patient begins to manifest the gravest symptoms, amend- 
ment takes place — the tongue never becoming dry and black, the de- 
lirium never occurring at other times than between sleeping and wak- 
ing. Next we have the typical case from which our description has 
been drawn, in which all stages are well developed and the commence- 
ment of convalescence is delayed to between the thirteenth and twenty- 
first day. Further, we meet with cases in which recovery is delayed 
by the supervention of complications or sequelae. And, lastly, cases 
occur in which the patient dies prostrate and delirious, or comatose, 
within the first week of the attack and even within the first day or 
two. 

Death is due for the most part to a combination of asthenia and 
coma. It is most common about the end of the second week. Oc- 
casional! v, and more especially in some epidemics than in others, the 
patient dies from the sixth to the eighth day. And many cases are 
recorded where death has occurred even so early as the first or second 
clay. Death at the end of the first week is often due in some measure 
to pulmonary congestion ; and after the fourteenth day either to the 
same, or some other, complication or sequela. The fatality of typhus 
is considerable. Of patients treated in hospital the mortuary rate is 
about 15 per cent. But these comprise an exceptionally large propor- 
tion of the gravest cases ; and there is reason to believe that the per- 
centage of deaths among all persons attacked with typhus is no more 
than 10 per cent. Among the causes which determine its fatality by 
far the most important is age. Under twenty the mortality is very 
low. Dr. Murchison's statistics, taken from the records of the London 
Fever Hospital, show a mortality in cases under five of 6.69 per cent. ; 
between five and ten, of 3.59 per cent. ; between ten and fifteen, of 2.28 
percent.; and between fifteen and twenty, of 4.46 per cent. Between 
twenty and twenty-five the mortality rises to 10.33 ; from which date 
upwards it increases pretty uniformly, lustrum by lustrum, until be- 
tween fifty and fifty-five it amounts to 49.62 per cent., and between 
seventy-five and eighty to 84.37. 

The sequelae of typhus are not very numerous or characteristic. 
Among the more important may be enumerated, bronchitis and pneu- 
monia, which may occur during the progress of the fever or during 
convalescence; gangrene, in the form of bed-sores, or affecting the toes, 
fingers, nose, penis or pudenda, or in children mainly in the form of 
noma; erysipelas; abscesses in the parotid or submaxillary region, or 
in the axillae or groins; suppurative inflammation (said to be pyaemic) 
of joints ; anasarca of legs, and mental imbecility or mania. These 
sequelae are all serious ; and two of them — noma and suppuration of 
the joints — are almost invariably fatal. 

Morbid Anatomy . — The post-mortem examination of typhus patients 
reveals little that is special. There is a tendency in the body to rapid 
decomposition ; the internal organs are for the most part softened and 
congested ; and the blood is dark, stains the vessels which contain it, 
and coagulates imperfectly. The lungs are generally deeply congested 
and very lacerable in their dependent parts, and sometimes solid from 



TYPHUS. 



185 



inflammatory changes. The spleen is generally softened, and not un- 
frequently somewhat enlarged. The large intestines occasionally show 
traces of dysenteric inflammation. 

Treatment — It is important that typhus patients should be treated 
in large, airy, well-ventilated chambers, and therefore that they should 
be removed from the overcrowded tenements which as a rule they oc- 
cupy. The attendants upon them should be seasoned and young. In 
the later periods of the disease, the bladder should, if necessary, be 
periodically emptied by means of the catheter, and the patient be kept 
scrupulously clean so as to prevent the formation of bed-sores. 

The general medicinal treatment of typhus is of little importance. 
There is no specific remedy, and no means which enable us to cut it 
short. It is, however, on the whole, desirable to relieve the thirst from 
which the patient suffers, and to promote the evacuation by the kidneys 
of the effete matters which speedily overload the blood. For this 
reason, so-called "febrifuge" medicines which are at the same time 
mildly diuretic are probably useful. Among them we may enumerate 
soda-water and chlorate, nitrate, citrate, or other salts of potash well 
diluted, acetate of ammonia, and the like. It is desirable also to keep 
the bowels fairly open either by occasional laxatives or by enemata. 
On the other hand, if there be diarrhoea it should be checked by opium 
or other ordinary forms of astringents. When pulmonary congestion 
complicates the progress of the fever, a little ipecacuanha or antimonial 
wine and a few drops of laudanum may be added to the mixture, or 
better still ammonia. If there be much insomnia or acute or busy 
delirium, opiates in larger doses may be administered by the mouth or 
subcutaneously, or recourse may be had to chloral or bromide of potas- 
sium. Rest, too, may be promoted by cutting the hair short or shaving 
it and applying cold lotions or ice to the head. It need scarcely be 
said that opiates should not be given when there is any tendency to 
coma, or to suppression of urine. In the typhoid stage of the malady, 
ammonia is probably the most valuable medicine. 

The exhibition of stimulants always becomes an important question. 
There is no doubt that in a large proportion of cases the patients do not 
require them; but there is no doubt, also, that many cases need them, 
and that few if any are injured by them in moderation. In persons of 
enfeebled constitution, in persons habituated to drink, and in such as 
are of advanced age, it is for the most part desirable to commence their 
administration early; and in all cases where the heart shows signs of 
unusual feebleness, where there is much prostration, or where typhoid 
symptoms are coming on, stimulants should be at once had recourse to. 
The amount to be given under such circumstances must depend on the 
condition of the patient, and on the effect which the stimulants produce. 
It matters little what form of stimulant is selected. 

From the beginning the patient loathes food; but the maintenance 
of his strength is imperative. Hence, those foods which he can be made 
to take should be given to him systematically in small quantities at 
frequent intervals. Nothing is better than good milk, of which, by 
judicious management, from two to three or four pints may often be 
given daily. But all patients will not take milk; alternative articles 



186 



SPECIFIC FEBRILE DISEASES. 



of diet are rice-water, barley-water, gruel, and eggs beaten up with milk, 
wine, or tea. Beef tea, broth, arrowroot, and jelly are useful adjuncts. 
Ice may often with benefit be added to the patient's drinks. 

During convalescence quinine or other forms of tonics are important; 
and the diet should be gradually modified to that of health, and should 
be abundant, frequently administered, and wholesome. 



PLAGUE. {Pestikntia. ) 

Definition. — A contagious fever, closely resembling typhus in its 
symptoms, but distinguished from it by the absence of any true rash, 
and by the development of buboes and carbuncles. 

Causation and History. — The early history of the disease to which 
the term "plague" is now applied is uncertain. It is known, however, 
to have prevailed from an early period of the Christian era in the 
countries which it now mainly affects — namely, Turkey, Asia Minor, 
Egypt, and Morocco — and to have spread thence at various times over 
the continent of Europe. In the seventeenth century numerous epi- 
demic outbreaks occurred in Holland and in this country, the last 
being the Great Plague of 1665. Since then it has occasionallv been 
imported into the countries bounding the Mediterranean basin and into 
Russia. In Asia Minor and in Egypt it may almost be regarded as 
endemic, occasionally, however, at irregular intervals bursting out into 
terrible epidemics. Whatever the specific cause of plague may be, it 
is certain that the epidemic occurrence of the disease is materially in- 
fluenced, if not determined, by conditions almost identical with those 
which determine outbreaks of typhus — namely, privation, filth, and 
overcrowding. Like typhus it affects mainly the poor, is apt to break 
out in armies engaged in warfare, and among the inhabitants of . be- 
leaguered cities. 

Plague is eminently contagious, and is communicated by the breath 
and by fomites, and can likewise be imparted by inoculation. The cause 
of its spread, therefore, is doubtless a specific contagium. Although an 
attack of the disease is to some degree protective, subsequent attacks 
have been abundantly met with. 

Symptoms and Progress. — The period of incubation is uncertain. 
The symptoms generally commence with chills or rigors, increase of 
temperature, pains in the forehead, back, and limbs, giddiness, anxiety, 
and sickness; on which rapidly supervene great loss of muscular power, 
extreme feebleness of the heart's action — indicated by rapidity, irregu- 
larity, and smallness of pulse, and prostration; and marked dulness or 
stupidity of expression, with corresponding hebetude of mind, passing 
speedily into delirium and coma and sometimes convulsions. The 
tongue, thickly coated from the beginning, soon becomes dry and black. 
The bowels are said to be generally somewhat loose, the urine scanty 
and occasionally suppressed. And haemorrhages from the various 
mucous surfaces are not unfrequent. 



PLAGUE — RELAPSING FEVER. 



187 



Within two or three days after the first appearance of symptoms 
petechia not unfreqnently appear over the surface of the body; and 
besides these, the more characteristic glandular swellings or buboes, 
which are chiefly to be detected in the neck, axilla?, and groins. Sub- 
sequently carbuncles become developed at various parts of the surface, 
generally, however, on the extremities. The appearance of petechise 
is by no means invariable, and is regarded as being of bad augury. 
The buboes enlarge, sometimes to a considerable size, reach their 
height (if the patient survive so long) at about the end of the eighth 
or ninth day, and then either subside or more rarely suppurate. Car- 
buncles are comparatively rare and for the most part show themselves 
towards the decline of the disease ; they vary in their size and intensity, 
and in numbers from one to about a dozen. 

Death from plague sometimes takes place within twenty-four hours 
after seizure. Severe cases not unfreqnently prove fatal on the second 
or third day of the disease. Many patients die on the fifth or sixth 
day. Occasionally death is delayed until the second or third week, 
being, however, then probably due in great measure to the effects of 
complications. 

It is generally acknowledged that it is impossible to distinguish 
plague positively from typhus, either by its early symptoms, or by the 
first few cases that come under treatment ; the mode of invasion and 
the general symptoms and progress of the two diseases presenting many 
points in common. Petechia? are frequent in both diseases, and 
buboes are of occasional occurrence in typhus. But plague does not 
present the true typhus rash ; and the buboes, which are quite excep- 
tional in typhus, are almost constant in plague; and, further, the mor- 
tality of plague is much greater than that of typhus, and its fatal issue 
occurs much earlier. 

Morbid Anatomy. — Patients dead of plague show, as in typhus, a 
rapid tendency to decomposition, fluidity or imperfect coagulation of 
blood, congestion and softening and enlargement of organs, and pete- 
chial extravasations beneath the serous and mucous surfaces. But 
besides these phenomena there is a general enlargement of the lym- 
phatic glands, which vary individually from the size of a goose's egg 
downwards. This enlargement is not limited to the superficial glands, 
but involves those of the interior of the thorax and abdomen, and is 
attended often with congestion and softening, and in some cases with 
suppuration. 

Treatment. — The rules and details of treatment which have been 
already given in regard to typhus are applicable to plague. No spe- 
cific remedies are known. Buboes and carbuncles call only for the 
usual treatment of such affections. 



KELAPSING FEVER. {Famine- Fever.) 

Definition. — A contagious disorder, characterized by a sudden attack 
of high fever, lasting for about a week ; then apparent convalescence, 



188 



SPECIFIC FEBRILE DISEASES. 



followed after about fourteen days from the primary accession by a 
second attack of fever. A further relapse now and then occurs about 
the twenty- first day. 

Causation and History. — The geographical limits of relapsing fever 
have not been fully ascertained. Our knowledge of it has been chiefly 
derived from epidemics originating in Ireland, whence it lias spread to 
England and Scotland. It appears to have broken out also inde- 
pendently in Scotland. Epidemics of it have within the last few years 
been observed in Russia and Silesia ; and there is good reason to be- 
lieve that it is not unknown in America, India, and parts of Africa. 
There seems clearly to be a very close relation between starvation and 
relapsing fever, which has hence been denominated famine-fever. All 
the more recent and most fully investigated epidemics appear to have 
arisen during the prevalence of extreme destitution, and among the 
classes who have mainly suffered from destitution. Further, although 
the disease is highly contagious and liable to affect all who come 
within its influence, it is mainly carried by tramps and vagrants; and 
when it spreads among populations not suffering from famine, still 
chiefly affects those who are least well-fed among them. Overcrowd- 
ing and filth are almost necessary accompaniments of famine; but 
these are not thought to have any special influence in the production 
of relapsing fever. At all events, when these conditions exist (as they 
often do) independently of famine, they are never known to promote 
the outbreak of the special famine-fever. Season and other climatic 
conditions appear to exert no influence over its development or spread ; 
and its attacks are probably in no degree determined by age or sex ; 
although it is true that statistics show a larger proportion of sufferers 
among males than among females. The contagion of relapsing fever is 
carried by the atmosphere and also by fomites. But there is good 
reason to believe that its influence extends but a short distance around 
the patient, that it is readily lost by dilution, and that in order to 
insure its action a large dose of poison or a long exposure to it is essen- 
tial. There can be no question that when the disease spreads its source 
is a specific contagium, which is evolved by the body already diseased 
and is absorbed by that which is about to suffer. It is a debated point, 
however, whether those who are primarily affected breed in their sys- 
tems the contagion which they afterwards evolve, or whether they have 
derived it from without from some source where it has lain latent ; in 
other words, whether during the progress of starvation the specific 
poison is engendered within the body, or whether the effects of starva- 
tion are such as to render the frame liable to be affected by a poison, 
which under other circumstances is innocuous. The question is one 
which scarcely yet admits of a positive solution. Those who look 
especially to the close connection between this fever and famine, and 
to the long intervals which elapse between successive outbreaks, natur- 
ally lean to the one view ; those who give weight to the analogies 
between it and the exanthemata lean as naturally to the other. A 
marked peculiarity of relapsing fever, as compared with other diseases 
of its class, is the fact that one attack does not confer safety from sub- 
sequent attacks; at all events, many persons have been known during 



RELAPSING FEVER. 



189 



one epidemic to be attacked with it two or three times at short inter- 
vals. It may be remarked, however, that the fact of a patient recover- 
ing spontaneously from an infective disease is a proof that he enjoys at 
least a temporary immunity from liability to be affected by it. And 
hence it may be assumed that immunity is actually conferred by an 
attack of relapsing fever, but that the period of immunity is mostly of 
very short duration. 

Symptoms and Progress. — The latent period of relapsing fever varies. 
Its extreme limits are probably two and sixteen days. Cases, however, 
are recorded in which the attack seemed to follow almost immediately 
on infection. Dr. Murchison concludes that the period of latency is, 
on the whole, shorter than that of typhus. 

The onset of the disease is for the most part sudden. The patient 
is attacked with a feeling of chilliness or with rigors, attended with 
severe pains in the forehead, trunk, and limbs. This condition is soon 
followed by intense heat and dryness of the surface, increased frontal 
headache, lumbar and other pains, giddiness, frequency of pulse, thirst, 
and loss of appetite. These latter symptoms continue with some slight 
variation, the dryness of skin alternating frequently with perspirations 
until the third, or more commonly the fifth or seventh day of the dis- 
ease ; when, preceded often by a slight rigor, a copious perspiration 
almost suddenly breaks out, which lasts for a few hours, and is fol- 
lowed by a remarkable reduction in the rate of the pulse and depression 
of the temperature, and, with the exception of some remaining lassitude, 
an almost complete restoration to health. 

The following is a more detailed account of the several symptoms 
which attend the febrile attack. The temperature almost from the 
commencement is very high, ranging often from 104° to 108.5° F. ; 
the pulse is rapid, generally over 110 and often reaching 130 or 140 in 
the minute ; the tongue is thickly coated with a white fur, the tip and 
edges being red ; and occasionally towards the termination the centre 
of the organ becomes dry and brown; the teeth are free from sordes; 
the patient suffers from extreme thirst, generally from anorexia and 
often from vomiting; in rare cases there is slight hsematemesis ; the 
bowels are mostly constipated ; there is often considerable tenderness 
in the region of the liver and spleen, both of which organs become in- 
creased in size; and in many cases jaundice appears about the second 
or third day ; the urine varies in quantity, but presents an excess of 
urea, and occasionally contains albumen and even blood ; towards the 
later period of the attack suppression may take place ; the pains in the 
head, trunk, and limbs, continue, all being severe, and the latter mainly 
affecting the joints, and presenting, therefore, a rheumatic character ; 
the patient for the most part retains perfect consciousness, but gener- 
ally suffers greatly from want of sleep and from frightful dreams when 
he does sleep ; delirium which may be maniacal sometimes occurs about 
the period of the crisis ; stupor, coma, and even convulsions supervene, 
though very rarely, about the same period, and are due then probably 
to ursemic poisoning. The patient rarely presents the -congested con- 
junctiva? and dull puzzled aspect of typhus fever. The critical per- 
spiration is occasionally attended with, or replaced by, an attack of 



I 



190 SPECIFIC FEBRILE DISEASES. 

diarrhoea or of haemorrhage from the nose, bowels, or some other part. 
No rash, except occasionally towards the end a few petechia?, is ever 
seen. 

During the period of intermission the temperature often falls below 
the normal, sinking sometimes as low as 96°, 94°, 92° or even 90.6°, 
and it continues low for the first two or three days ; the pulse also falls 
to 40, 50, or 60 in the minute, though liable to sudden increase on 
exertion ; the tongue becomes clean and the appetite often voracious. 
Occasionally, at the commencement of this period, the patient falls into 
sudden collapse, or passes into a typhoid state ; but far more frequently 
he appears, with the exceptions above adverted to, restored to perfect 
health. 

Sometimes the first paroxysm of fever is the only one. More com- 
monly, however, at the end of fourteen days (more or less) from the 
first accession of symptoms the patient suddenly experiences a recur- 
rence of his febrile attack. The symptoms which now ensue are as 
nearly as possible identical with those from which he formerly suffered. 
The temperature, however, is often higher, and the duration of the 
attack for the most part shorter. It generally lasts about three days, 
at the end of which time convalescence is ushered in with the phenom- 
ena which had previously ushered in the remission. 

Occasionally a third paroxysm takes place on or about the twenty- 
first day ; and a fourth and even a fifth recurrence have been observed, 
though very rarely. 

The danger to life from relapsing fever is comparatively very slight. 
Dr. Murchison's statistics show a mortality of 4.75 per cent. only. 
The causes of death are mainly asthenia and collapse — the latter of 
which may occur quite suddenly about the period of crisis — coma and 
other cerebral complications, and its sequelae. [There is evidence, 
however, showing that relapsing fever is much more apt to terminate 
fatally in the negro than in the white race. Thus in the winter of 
1869-70, when the disease prevailed epidemically in Philadelphia, the 
large relative mortality among the former excited very general atten- 
tion. 1 This fact contrasts very remarkably with that of the immunity 
which this race enjoys as regards yellow fever.] 

Convalescence is generally protracted, the patient very slowly re- 
gaining strength, but is not frequently complicated with serious sequelae, j 
Amongst the most common of these are pulmonary affections (more 
especially pneumonia), diarrhoea, and dysentery. The most character- 
istic of them all is ophthalmia. It is a remarkable phenomenon of 
relapsing fever that pregnant females affected with it almost invariably 
abort, and this no matter what period of gestation they may have 
reached. The foetus moreover dies ; the mother, as a rule, recovers. 

Morbid Anatomy. — Excepting for the presence of such lesions as are 
due to accidental complications and sequelae, nothing very characteristic 
is noticeable after death. The liver is usually enlarged and congested, 
but otherwise (even if jaundice be present) apparently healthy; and 



1 [According to the report of the Board of Health, of 162 deaths from relapsing 
fever occurring in Philadelphia during the j^ear 1870, 107 were of negroes.] 



DENGUE. 



191 



the spleen is invariably enlarged to several times its normal bulk, and 
generally softened or diffluent. 

Treatment. — In the treatment of this disease it is of course neces- 
sary, in order to prevent its spread, to isolate the sick, and to take the 
ordinary hygienic precautions in respect of ventilation and the like. 
In every case the disease will probably run its course whatever treat- 
ment be adopted. It is important, nevertheless, to alleviate symptoms 
and to avert complications. To diminish heat, cold sponging may be 
serviceable; to check vomiting, ice; to relieve headache and other 
pains and to promote sleep, perfect quiet, opium or morphia in medium 
doses, chloral, and counter-irritant or sedative applications; to obviate 
constipation and portal congestion, mild laxatives such as castor oil, 
or enemata ; and to encourage diuresis, non-stimulating diuretics, such 
as bland drinks, and medicines containing chlorate, nitrate, or acetate 
of potash, or acetate of ammonia. If coma, attended with suppression 
of urine, occurs, it may be necessary to give purgatives, and to apply 
cupping-glasses over the lumbar region. Emetics are recommended 
by many to be given early in the disease ; and bleeding has also been 
strongly advocated. During the febrile attack, the nourishment should 
be such as is usually proper for patients suffering from febrile disorders. 
Alcoholic stimulants are rarely necessary, excepting when there is any 
tendency to collapse. 



DENGUE. {Dandy Fever.) 

Definition. — A specific affection, characterized by high fever, inflam- 
mation of the joints, a peculiar rash, and a tendency to be continued 
for a few weeks by intermittent attacks of short duration. 

Causation and History. — Nothing seems to have been known of this 
disease until the year 1 824, when it broke out suddenly in Rangoon 
among a body of troops. Thence it spread, and since that time has 
occurred in occasional epidemics in different parts of India, and also in 
the tropical parts of North America and in the West India Islands, into 
which it was introduced from the East Indies. It does not appear to 
have extended to temperate regions. Dengue is contagious in a very 
high degree, and doubtless, like other such diseases, depends upon a 
specific virus communicated from the sick to the healthy. Its conta- 
giousness, indeed, is almost as virulent as that of influenza; and it 
spares neither male nor female, young nor old. 

Symptoms and Progress. — Little or nothing is known with respect to 
the period of incubation of dengue, or with respect to the amount of 
protection one attack affords. The invasion is sometimes preceded by 
slight premonitory symptoms, but much more frequently is quite sud- 
den. Among the early phenomena of the disease are high fever, with 
sense of chilliness or actual rigors, alternating with flushes of heat; 
dryness of skin ; severe frontal headache with vertigo ; aching in the 
eyeballs; pain along the spine and in the limbs, but more particularly 
in the joints; great rapidity and hardness of pulse; acceleration of 



192 



SPECIFIC FEBRILE DISEASES. 



respiration ; furred tongue, and heat and pain at the epigastrium, with 
loss of appetite and very frequently sickness; great muscular prostration, 
restlessness, and inability to sleep. With the advance of the disease, 
the prostration and the febrile symptoms undergo aggravation j the face 
and the conjunctivae become congested, the pulse rises to 1*20, 130, or 
even 140, the tongue becomes coated, except at the tip, with a thick, 
white, moist fur, the pains (especially those in the joints) augmented — 
the arthritic pains, indeed, tending to shift about as in ordinary 
rheumatism, and the affected joints (especially the smaller ones) to 
become swollen. In the course of a day or two, however, perspirations 
break out, and the severity of the symptoms seems to abate somewhat; 
but on the third or fourth day of the disease, or a little later, some 
increase of pain takes place, and is attended with an evanescent 
eruption, which, commencing on the hands and feet, speedily spreads 
over the whole cutaneous surface. This eruption has been likened to 
that of scarlet fever, measles, urticaria, or erythema. From the descrip- 
tions it would seem to be a kind of erythema papulatum, such as is not 
■infrequently met with in cases of acute rheumatism. It is said to dis- 
appear usually on the second day, to be attended with more or less 
itching, and to be followed by desquamation. It is not invariably 
present. With the subsidence of the rash, or about the fifth, sixth, or 
seventh day of the disease, the febrile and other symptoms abate, the 
patient becomes convalescent and is then soon restored to comparative 
health. In a short time, however, a relapse, almost as severe in its 
symptoms as the primary attack but lasting for two or three days only, 
occurs; and to this, after intervals of apparent convalescence, a second 
and perhaps a third relapse succeed. Much debility usually, and not 
unfrequently pain, stiffness or swelling of the joints, persist after the 
final cessation of the febrile attacks; and health is not generally com- 
pletely restored under a period of three months. It is important to 
observe that, notwithstanding the high fever, the extreme pain, and 
the general severity of the symptoms under which the patient labors, he 
rarely suffers from delirium, or fails to make a good ultimate recovery. 
Occasionally death occurs early in the disease, during the period of 
defervescence, from syncope. 

Other phenomena which patients suffering from dengue occasionally 
present, are, bleeding at the nose, swelling of the parotids, with saliva- 
tion, swelling of the lymphatic glands or of the testicles, jaundice, and 
ophthalmia. It maybe added that the appetite in some cases continues 
unimpaired, and that pregnant women rarely abort. 

It is obvious that the phenomena of dengue have a considerable 
resemblance, in some aspects, to those of rheumatism, ague, scarlet 
fever, and measles, with each of which it has been confounded. It 
much more closely, however, resembles relapsing fever. It resembles 
this in its virulence of contagion, in its sudden access, in its high tem- 
perature, with headache and arthritic pains, in the rareness of the occur- 
rence of delirium, in its tendency to be continued by several successive 
relapses, in its little mortality, and even in some of the details of symp- 
toms and sequelae, such as the condition of tongue and of appetite, the 
occasional occurrence of jaundice, of ophthalmia, and of inflammation 



YELLOW FEVER. 



193 



of the salivary and other glands, and even in the occasional superven- 
tion of death from syncope during the period of defervescence. The 
eruption of dengue (if it be specific) may seem to indicate a difference 
between them, as also may the intensity of the arthritic inflammation 
which attends it. Can it be relapsing fever modified by climate? 

Of the morbid anatomy of dengue nothing of any importance is 
known. 

Treatment. — The treatment must be that applicable to other fevers 
over wdiose course we have no control. Emetics and purgatives have 
been strongly advocated, but, on the whole, it is probably best to 
administer saline or other cooling medicines. The headache and 
arthritic pains may be relieved by local applications or by the use of 
opiates, and complications may call for special treatment. During con- 
valescence quinine or other tonics are indicated. 



YELLOW FEVER. 

Definition. — A contagious, continued fever, of short duration, char- 
acterized especially by epigastric tenderness, vomiting, hsematemesis, 
and jaundice. 

Causation and History. — This disease prevails in certain tropical 
regions, especially in the West India Islands, which seem to be its 
home, and in the neighboring portions of the continents of North and 
South America, but it occasionally invades countries correspondingly 
situated in the Old World, and has even been introduced into the sea- 
port towns of England, France, and other parts of Europe. It seems 
never to spread, however, in these latter situations, excepting at times 
of excessive heat. A high temperature appears to be an essential con- 
dition of its prevalence. It is said, indeed, that it never spreads when 
the thermometer stands at less than 72° Fahr., and that even when it 
is epidemic in a place, it rarely, if ever, attacks those who live more 
than 2500 feet above the level of the sea. Outbreaks of yellow fever 
are probably promoted by local conditions of general insalubrity, and 
the intensity of the disease is doubtless augmented by them. The essen- 
tial cause, however, of yellow fever, is a specific contagium of extreme 
virulence, which is given off with the breath, and probably other secre- 
tions, diffusing itself in the atmosphere, and attaching itself to fomites, 
which remain infectious for a long time. [American physicians, espe- 
cially those whose opportunities give them the best right to speak 
authoritatively on this point, do not admit the contagiousness of yellow 
fever in the full sense of the term. In Philadelphia, where in recent 
years it has occurred only at long intervals, it has always been trace- 
able to the arrival of a vessel from an infected port, bringing with 
it the fomites of the disease. It has invariably affected those whose 
occupations have taken them on board the ship or in its immediate 
neighborhood, or those who have lodged the sailors, the latter un- 
questionably often carry the fomites of the disease from the ship in 

13 



194 



SPECIFIC FEBRILE DISEASES. 



their clothing. It has, almost without exception, been confined to the 
part of the city in which it first originated, and, s© far as is known, no 
case is on record in -which a person, having the disease in a previously 
healthy quarter, has become the starting-point of a local epidemic, as is 
so frequently observed in measles, small-pox, or, in fact, in any of the 
truly contagious diseases. The fact, too, that it rarely appears else- 
where than in seaport towns, is an argument against its communica- 
bility.] There is no good reason to believe that this disease ever arises 
spontaneously. It spares neither age nor sex, but one attack confers 
on the sufferer immunity from other attacks. 

Symptoms and Progress. — The period of latency of yellow r fever is 
said to vary between two and fifteen days. Most commonly it ranges 
from six to ten. At the end of this period the patient is generally 
attacked suddenly with acute febrile symptoms, marked by shivering, 
increased temperature (101° to 105°), dryness of skin, congestion of 
face, redness, suffusion and aching of eyes, acceleration of pulse, thirst, 
anorexia, pains in limbs, and intense frontal headache, to which are 
soon added acute lumbar and spinal pains, slight epigastric tenderness, 
and vomiting of the mucous and other contents of the stomach. The 
tongue is generally coated with a thick, creamy fur, except at the tip 
ancWdges, which are preternaturally red. After these symptoms have 
lasted, with some variation, for a day or two, the febrile condition, and 
the intense frontal and rhachidian pains, are apt to subside somewhat. 
But, for the most part, the epigastric tenderness becomes more pro- 
nounced, and the vomiting more constant, and a slight yellowness of 
the conjunctivae may perhaps be recognized. On the third or fourth 
day, or later, the vomited matters, hitherto colorless or yellow, begin 
to contain blood — sometimes bright, more commonly in the form of sus- 
pended particles of black pigment — and soon assume, from the more co- 
pious admixture with blood, a coffee-grounds character, constituting the 
so-called "black vomit." At the same time the motions are often dark 
or black from the like cause. If the patient do not at once sink, symp- 
toms of a typhoid character are apt to supervene, the vomiting may or 
may not continue, the skin probably becomes more decidedly jaundiced, 
and at the same time dusky, the teeth covered with sordes, the tongue 
dry and black, the pulse quick and feeble, an eruption of red spots or 
of petechias often makes its appearance on the trunk, and drowsiness, 
convulsions, delirium, maniacal excitement, or coma, supervenes. From 
the second or third day the urine contains albumen, occasionally a little 
blood. Later on it becomes scanty, and is sometimes suppressed. 

Convalescence may (according to the severity of the attack) com- 
mence from any period of the disease, is marked by the gradual sub- 
sidence of the graver symptoms, and is generally completed at the end 
of two or three weeks. The jaundice, however, is slow to disappear. 
The fifth day is often regarded as critical. 

The mortality from yellow fever is very high, and death occurs at 
various periods in its course. In some cases the attack is so sudden 
and so severe that the patient dies in a state of collapse at the end of a 
few hours. More commonly he sinks at the end of tw T o, three or four 
days, during the period of the occurrence of black vomit — his death 



YELLOW FEVER. 



195 



then being for the most part due to sudden collapse, determined mainly 
probably by gastro-intestinai haemorrhage. Death is not unfrequently 
thus produced at this time in patients who have seemed to be going on 
quite favorably, and even in those who have hitherto suffered so little 
from the disease that they have not been confined to bed, and have even 
been able to follow their employments. At a later date death is due 
sometimes to cerebral complications, referable probably to ursemic 
poisoning, sometimes to gradually increasing exhaustion. 

The symptoms which collectively are most characteristic of yellow 
fever are sudden onset with high fever, frontal and lumbar pain, epi- 
gastric tenderness, hemorrhagic vomiting, and jaundice. But any of 
these symptoms (and more especially the last two) may be absent. And, 
indeed, the symptoms of the disease are generally liable to great varia- 
tion. This variability depends to a great extent on the degree of 
severity of the attack, and on the relative degrees in which the several 
parts of the organism are affected. Mild cases of the disease often pre- 
sent no characteristic features whatever, and may be readily confounded 
with similarly mild attacks of other continued fevers. In its sudden 
onset with frontal headache, lumbar pain and vomiting, it closely re- 
sembles variola, from which, however, it soon becomes differentiated. 
Relapsing fever, again, in its sudden development with fever, headache, 
pain in the back, and vomiting, followed in a day or two by jaundice, 
presents a marked resemblance to yellow fever; but it differs from it 
widely in its little fatality, in the absence of black vomit, in its sudden 
cessation at the end of a few days, and in the subsequent relapse. 
Malarial remittent fevers may also be confounded with yellow fever, 
but are distinguishable by many features ; they are endemic and not 
contagious, one attack favors subsequent attacks, the febrile paroxysms 
intermit, there is enlargement of the spleen, and gastro-intestinai 
haemorrhages, if they occur, are copious and sudden. Yellow atrophy 
of the liver may be distinguished by its gradual commencement, with- 
out marked fever, pain or other characteristic symptoms of yellow fever; 
at a later period, when the skin becomes yellow, the epigastrium tender, 
and delirium supervenes, the diagnosis may be difficult. Lastly, it 
may be remarked that jaundice is not uncommonly developed in the 
course of various fevers and inflammations, and cannot therefore be 
regarded as a distinctive mark of yellow 7 fever. 

Morbid Anatomy. — The principal morbid conditions observed after 
death from yellow fever, are, as might be predicted from the symptoms, 
to be discovered in the liver and the mucous membrane of the alimen- 
tary canal. The liver is generally pale, soft, yellowish, or clay-colored 
(as it is in many other acute febrile states attended with jaundice) and 
somewhat enlarged. [These changes in the appearance of the liver 
were attributed by Professor Clarke, of New York, and by Dr. T. Hew- 
son Bache, of Philadelphia, who found an excess of oil in the liver, to 
acute fatty degeneration. More recent observers have ascribed them to 
j inflammatory action.] The mucous membrane of the stomach is for 
the most part soft and injected, and the cavity of the organ usually con- 
tains disintegrated and blackened blood. Similar congestion and simi- 
lar contents may also be met with in the intestines. Peyer's patches 



196 



SPECIFIC FEBRILE DISEASES. 



are unaffected. The spleen is soft, but not enlarged. Haemorrhages 
are not uncommonly met with in the lungs and various other parts. 
Nothing else noteworthy has been detected. 

Treatment. — Many drugs have been recommended and used in the 
treatment of this disease. Large doses of calomel and large doses of 
quinine have both been tried. But it seems probable that they have 
done no good, if not harm. The patient should be confined strictly to 
bed, and not allowed to make any exertion. He should be kept cool, 
in an apartment well ventilated and devoid of hangings. The secretions 
of the skin and kidneys should be encouraged by diluent drinks, and 
the bowels kept freely open — preferably by enemata. Vomiting should 
be counteracted by ice, and medicinally by lime-water, hydrocyanic 
acid, spirits of chloroform, bismuth, or other stomach-soothing drugs. 
Wakefulness and delirium may be treated with opiates; headache, pre- 
cordial uneasiness, and lumbar pains relieved by the local application 
of counter-irritants, cold, or anodynes. Constant vomiting precludes 
generally the successful administration of food. Under any circum- 
stances, however, this should be bland and unirritating, and given fre- 
quently and in small quantities. Nothing can be better than milk, 
barley-water, rice-water, or gruel.. No doubt the great tendency to fall 
into collapse is suggestive of speedy recourse to alcoholic stimulants. 
Of these brandy and the effervescent wines have been most recom- 
mended. They should, however, be given diluted and with caution ; 
for, however beneficial they may prove if absorbed, their local influ- 
ence on an irritable and bleeding stomach can scarcely be otherwise 
than injurious. 



CEREBRO-SPINAL FEVER. (Epidemic Cerebrospinal 

Meningitis.) 

Definition. — A specific contagious fever, characterized by inflamma- 
tion of the membranes of the brain and cord, and by the symptoms 
which these lesions induce, and attended frequently with petechia?, 
collapse, and an early termination in death. 

Causation and History. — This disease has only been distinctly recog- 
nized from the t ime of its epidemic prevalence in various parts of France 
between the years 1837 and 1848. Since its first appearance in that 
country it has broken out at various times in Italy, Algeria, Gibraltar, 
Portugal, Holland, Denmark, Sweden, Norway, North Germany, and 
Ireland. In Ireland the disease prevailed between the years 1846 and 
1850, and again with considerable severity between 1865 and 1867. In 
Dantzic a notable epidemic occurred in the years 1864 and 1865. In 
the United States cerebrospinal fever became prevalent about the 
same time as in France; and since then there have been frequent out- 
breaks in different parts of that country. It is by no means clear that 
there has ever been any prevalence of the disease in Great Britain. 
Age and sex, social condition, and ordinary sanitary circumstances ap- 



CEREBRO - SPINAL FEVER. 



197 



pear to exert little influence over the origin and spread of cerebro- 
spinal fever. Nevertheless, males seem on the whole to have suffered 
in larger proportion than females, and soldiers in garrison, in many 
epidemics, more severely than other sections of the population. It ap- 
pears, also, to be indisputable that the disease occurs mainly during 
the winter months; and Mr. Netten Radcliffe remarks "that it is note- 
worthy that the northern and southern limits of distribution in both 
hemispheres but slightly overlap the isothermal lines 5° and 20°." 
Cerebro-spinal fever is certainly epidemic. Is it also infectious? Of 
this we think there can be little doubt ; although it must be admitted 
that neither the contagium has yet been recognized, nor the route by 
which it leaves the body of the sick or that by which it enters the body 
of the healthy yet discovered, nor its behavior external to the body yet 
ascertained. It is important, however, to note that the mode of its 
epidemic prevalence is not unlike that of cholera or of typhoid fever 
in the facts that it is marked by numerous scattered and for the most 
part small outbreaks, rather than by a general widespread diffusion, 
and that the disease, like these others, although giving clear indication 
of its spread from the sick to the healthy, presents little or nothing of 
the virulence of direct contagion which characterizes most of the exan- 
themata. 

Symptoms and Progress. — Cerebro-spinal fever is attended in some 
cases by premonitory symptoms, lasting from a few hours to several 
days, and comprising mainly feverishness, malaise, headache, and pains 
in the back, abdomen, and limbs; but in many cases it comes on quite 
without warning. In either case the first symptoms of the actual out- 
break are severe rigors; intense headache with vertigo; persistent 
vomiting with more or less severe pain in the stomach; and pains along 
the spine and in the muscles of the extremities, attended often with 
spasmodic contraction. The patient soon becomes restless or irritable, 
voluble or taciturn, and more or less obviously delirious or the subject 
of delusions, and not un frequently drowsy; his head is thrown back, 
and retained in that position, not so much from spasm in the muscles 
of the neck, as from a voluntary effort to relieve pain in that situation ; 
and his limbs become flexed. He probably cries out at times, or 
screams with the intensity of the pain in his head and back. But 
gradually his mind gets more distinctly affected; he becomes less alive 
to pain and other subjective phenomena; he passes into a condition of 
busy or of muttering delirium or into one of acute maniacal excitement, 
occasionally has convulsions, and then lapses more or less gradually 
into profound coma. In a considerable proportion of cases, a purpuric 
eruption makes its appearance in greater or less abundance, and more 
or less generally distributed, from the second to the fourth day. Death 
may occur during the first day or two (occasionally after a few hours 
only) from collapse; or from this time to the seventh or eighth day 
from coma due to the cerebro-spinal lesion ; or at a later period, even 
up to the sixth or seventh week, from one or other of the complications 
which are apt to ensue. 

The above is a sketch of the symptomatic phenomena of the disease 
in its ordinary form ; and, as will be observed, they are mainly those 



198 



SPECIFIC FEBRILE DISEASES. 



of non-specific inflammation of the membranes of the cord and brain. 
They vary much, however, in their severity in different cases, and are 
frequently conjoined with other symptoms which are also for the most 
part dependent on the cerebro-spinal lesion. We will consider them 
seriatim,, as they are referable to different conditions and different 
organs. Fever is not usually a marked feature of the disease. The 
temperature appears in many cases never to rise above 101°; it may, 
however, in the course of the malady reach 105°; and in cases which 
are rapidly fatal, with symptoms of collapse, it may even sink below 
the normal. The skin varies in its condition, but is rarely pungently 
hot and dry or profusely perspiring.. Besides the petechial eruption 
which has been described, it occasionally presents patches of erythema 
or roseola; or groups of herpetic vesicles appear upon the lips. Res- 
piration in severe cases is more or less embarrassed. It is generally 
then slow and suspirious, but with the increase of depression becomes 
hurried and shallow. The pulse is much enfeebled, but its frequency 
is liable to great variation : sometimes it is preternaturally slow, some- 
times exceedingly frequent ; and rapid alternations are apt to occur 
without any obvious cause. The g astro-intestinal phenomena are of 
some importance. Violent sickness is a noteworthy symptom of the 
disease during its earlier periods. It comes on without any necessary 
sense of nausea, and independently of the ingestion of food. As the 
disease advances it usually ceases. The severe abdominal pain which 
commonly occurs about the same time is also an important symptom ; 
it appears to be strictly neuralgic, and like the vomiting itself refer- 
able to the condition of the central nervous organs. The tongue may 
be clean, or more or less furred, and with the progress of the disease is 
apt to become dry. The bowels are for the most part constipated. 
The urine in some cases contains albumen and blood. The more im- 
portant symptoms referable to the nervous system, namely, neuralgic 
pains, delirium, and coma, have already been enumerated, and we need 
not recur to them. We may, however, point out that numerous addi- 
tional phenomena are apt to present themselves. The patient not only 
suffers from intense pain in the head, not necessarily limited to any one 
locality, but from pain in the course of the spine and especially in its 
cervical region, and from neuralgic pains in the belly and in the course 
of the limbs. Cutaneous hyperesthesia is sometimes present. We 
have pointed out that general convulsions are occasionally observed ; 
but more common perhaps than these are local spasms either of the 
tonic or the clonic kind in various groups of muscles, or tremors and 
snbsultus. Paralysis, either hemiplegic or limited to a limb or some 
other portion of the organism, occasionally supervenes ; or there may 
be anaesthesia. Deafness, loss of sight, squinting, inequality of pupils, 
and the like, are also occasionally met with • and, sometimes, intoler- 
ance of light or sound. With the supervention of coma, and often 
before that period, there is loss of control over the bladder and rectum. 
The attitude which the patient assumes is characteristic at all events of 
cerebro-spinal inflammation ; and his aspect generally affords clear 
indications of the condition of his cerebral and spinal functions. 

If the case be of long duration, various phenomena, due apparently 



CEREBRO-SPINAL FEVER. 



199 



to irritation of the nerves or of the centres whence they emerge, are apt 
to ensue — amongst them, destructive inflammation of the cornea or 
other parts of the eye, or of the internal ear; inflammation, often 
attended with suppuration, of the large joints; parotid swellings and 
bed-sores. Inflammatory affections of the thoracic organs are also not 
un frequent. 

The percentage of deaths in cerebro-spinal fever has varied in differ- 
ent epidemics between 20 and 80. 

Morbid Anatomy. — The morbid changes observable after death are 
definite and simple. They consist in congestion of the vessels of the 
pia mater of the brain and cord, and in inflammatory exudation into 
the subarachnoid tissue and occasionally into the ventricles. This 
exudation is sometimes transparent and watery, but more frequently 
opaque, greenish, and distinctly purulent. The affection is sometimes 
general, but more commonly localized to some extent, and not unfre- 
quently confined mainly to the base of the brain, especially its posterior 
part, and to the surface of the medulla oblongata and upper part of the 
spinal cord. There is often, also, more or less congestion of the sub- 
stance of the brain. It is said that in some of those cases in which 
death has occurred speedily from collapse no characteristic lesions have 
been detected. 

Treatment. — The treatment of cerebro-spinal fever has probably not 
been more successful in its results than that of any other of the specific 
fevers. It must, however, be borne in mind that the mortality of this 
disease is due, less to the direct influence of the specific poison of the 
disease than to the cerebro-spinal inflammation which is one of the 
immediate consequences of its operation. If, therefore, meningeal in- 
flammation be amenable to treatment, it is reasonable to believe that 
that of cerebro-spinal fever should be to some extent within our control. 
Powerful depletory measures, however, and above all the abstraction of 
blood are on several grounds obviously contraindicated. Counter- 
irritation, or cold to the head and along the spine, and moderate pur- 
gation may possibly be of some benefit, as also may the use of cooling 
saline draughts. Opium in large and frequently repeated doses, and 
quinine in large doses, have found much favor with American physi- 
cians. [In addition to these remedies, ergot and bromide of potassium 
have been used with great asserted success in the treatment of this dis- 
ease. And certainly the latter remedy possesses, in a higher degree 
than any other, the power of relieving the violent headache which is 
often the cause of much suffering to the patient. This symptom is also 
much relieved by the application of a few cut cups to the back of the 
neck.] The food which is administered should be in the fluid form ; 
and its regulated exhibition should be enforced. When symptoms of 
collapse manifest themselves, stimulants may be had recourse to, and 
the surface should be kept warm. 



200 



SPECIFIC FEBRILE DISEASES. 



DIPHTHERIA. {Membranous Croup.) 

Definition. — A contagious disease, of which the more characteristic 
phenomena consist in the formation of whitish membranous pellicles 
on certain mucous surfaces (more especially those of the fauces, nares, 
larynx, and trachea), and on excoriated or wounded arese of the skin; 
the rapid development of anaemia and extreme debility; and the super- 
vention, during apparent convalescence, of temporary paralysis. 

Causation and History. — This disease, although it has been described 
by many authors of ancient and modern times, has been known by its 
present name only since the publication of Bretonneau's treatise in the 
year 1826. He designated it "diphtherite" (since modified into diph- 
theria) from the Greek word dupdipa, a skin. Diphtheria, like most 
other infectious diseases, is met with in the sporadic form, and from 
time to time breaks out into virulent and widespread epidemics. Many 
of these have been recorded. The last of any serious importance pre- 
vailed extensively in France during the years 1855, 1856, and 1 857, 
and was imported thence into our own country, where, from 1859 to 
1862, it committed great ravages. It was then indeed regarded by a 
large number of the most experienced physicians as a disease almost, 
if not quite, new to the country. They were well acquainted with 
membranous inflammation of the trachea, or croup — a disease, too, 
which had been known to occur in an epidemic form; but they failed 
to see, as many indeed still fail to see, that between the characteristic 
forms of croup, from which the classical description of the disease was 
taken, and diphtheria there is no essential difference. The Scottish 
and English physicians of the latter part of the last century and the 
early part of this had their attention particularly directed to the rapidly 
fatal laryngeal form of the disease, and described it as a local affection. 
Bretonneau, on the other hand, recognized that the laryngeal affection 
was the occasional complication only of a general disease which was 
infectious and presented other remarkable features beyond the mere 
formation of a membranous lining to the air-passages. Thus the same 
disease, described from different points of view and from different de- 
grees of acquaintance with its pathology, and receiving different names, 
came to be regarded as two distint diseases. And hence as much con- 
fusion has arisen, and as much difficulty in recognizing the exact truth, 
as in the inverse case of disentangling enteric fever and typhus from 
the discordant descriptions of the presumed single disease, continued 
fever. - 

Diphtheria is a disease of all countries and of all seasons, and affects 
both children and adults. It is nevertheless far more common among 
young children, especially between the ages of three and six, than in 
persons of more mature age, and is both actually and relatively much 
more fatal to them. There is reason to believe that the sanitary state 
of houses or localities, and the condition of health of those who are 
exposed to its poison, have much influence over its development. It 
is not, however, very clear what forms of uncleanliness or what con- 
stitutional conditions are most influential in this respect; for we know 



DIPHTHERIA. 



201 



that those who appear to be in the best of health often take it, while 
the weakly escape ; and that it attacks the wealthy and the clean as 
well as the poor, the filthy, and the overcrowded. Diphtheria is un- 
doubtedly contagious ; the epidemic of 1859-62 was distinctly imported 
into this country from France; the introduction of a case into a house 
or hospital or other institution, containing many inmates, is almost 
certain to be followed by an outbreak of the disease amongst them, and 
indeed it not uncommonly happens that in this way every child of a 
large household is swept away ; the nurse contracts it from her charge, 
the doctor from his patient, the mother from her suckling. The con- 
tagion is doubtless for the most part carried by the atmosphere. But 
it may also lie dormant in fomites, and thus present prolonged vitality; 
for it is certain that many cases have been met with in which children, 
who have been brought into rooms which had been well purified sub- 
sequently to the occurrence of diphtheria in them several weeks or 
even months previously, have taken the disease. There is no doubt 
that it can be imparted by inoculation. Many cases are recorded (such, 
for example, as that of Professor Valleix, in whom a fatal attack su- 
pervened on the reception into his mouth of a small quantity of saliva 
coughed out by a diphtheritic child) where accidental inoculation seems 
to have been efficacious; yet, on the other hand, both Trousseau and 
Peter have experimentally inoculated themselves without effect. Ex- 
periments upon the lower animals have latterly been largely performed, 
but with results which are not entirely conclusive. The most im- 
portant are those of Letzerich, Oertel, and Trendelenburg, in which 
they claim to have given diphtheria to rabbits by the introduction of 
diphtheritic matter into the trachea. 

It may be presumed that the patient is most apt to impart the dis- 
ease while the membranous exudations are present; but it is by no 
means certain at what period he ceases to be infectious. Convalescent 
children — children, that is, who appear to be perfectly well and have 
been apparently well for two or three weeks — seem occasionally to 
have given the disease to others. 

Symptoms and Progress. — The period of incubation is not accurately 
known. Some patients appear to have contracted diphtheria a few 
hours only after exposure to its virus. In others the disease has not 
manifested itself for as much as eight days after exposure. The incu- 
bative period probably varies between these extremes. Whether it is 
ever more prolonged must be regarded as doubtful. The symptoms 
which attend the invasion of diphtheria vary in some degree in their 
intensity with the virulence of the attack they usher in. For the most 
part they consist in elevation of temperature and other evidences of 
febrile disturbance, together with slight uneasiness or soreness of the 
throat. But these are often so slight that the patient makes little or no 
complaint and pursues his ordinary avocations, until perhaps (espe- 
cially if he be a child) attention is attracted to him by the presence of 
pallor, languor, and dulness or tendency to mope. Sometimes the 
febrile symptoms are much more marked, and there may be distinct 
chills or rigors ; but there is rarely even here any great complaint as 
to the condition of the throat. If, on the first evidence of illness, the 



202 



SPECIFIC FEBRILE DISEASES. 



interior of the throat be examined, there will probably be observed 
some degree of redness and tumefaction of the tonsils, pillars of the 
fauces, soft palate or pharynx, or of all of these parts. And very soon 
afterwards whitish or grayish or buff-colored opaque well-defined 
patches will be visible on some parts of the congested surface, often on 
one or both tonsils. These vary in thickness, are more or less coher- 
ent, admitting of removal in shreds or as a whole, and are moderately 
adherent to the subjacent surface, which is left excoriated but not ex- 
cavated by their removal. They tend rapidly to spread, and hence if 
multiple to coalesce, and at the same time to become thicker and more 
adherent, and may thus, in the course of a few days, form a nearly 
continuous covering to the whole surface above indicated, including 
that of the uvula. And, indeed, the throat may be found to be already 
in this condition at the time when attention is first seriously attracted 
by the general aspect of illness which the patient presents. By this 
time the tonsils are often considerably enlarged, and the uvula swollen 
and cedematous; there is almost invariably some manifest swelling and 
tenderness of the lymphatic glands about the angles of the jaw; there 
is generally also more or less mucous exudation and accumulation 
about the fauces; but rarely either the total loss of appetite or the 
great agony in mastication and swallowing which attends ordinary 
tonsillitis. 

The course which the disease may take from this point is very 
various. In some cases the febrile symptoms soon subside, the morbid 
process ceases to spread, and the patient undergoes rapid convales- 
cence. In some cases the membranous formation extends along the 
oesophagus, reaching it may be to the stomach. In some it spreads to 
the larynx and trachea, and occasionally thence to the bronchial tubes. 
In some it invades the posterior nares, extending possibly throughout 
the whole of the nasal cavity and even along the lachrymal ducts to 
the conjunctivae. In some the inflammation spreads in depth, and the 
glands and other soft tissues in the submaxillary and adjacent regions 
become swollen and infiltrated with inflammatory matter. And in 
some diphtheritic pellicles make their appearance on other mucous 
surfaces, or on excoriated or ulcerated portions of the skin. We will 
discuss these various cases categorically. 

1. The first of the above varieties of diphtheria is frequently a very 
mild disorder. The patient — with little or no fever at any time, with 
scarcely any complaint of soreness of throat, with no material thirst or 
loss of appetite, and with perhaps a small white patch on one or other 
or both tonsils, which may even have disappeared before the throat 
comes to be examined, or which may be detached at the end of three 
or four days, or a little later — becomes convalescent in the course of a 
week or ten days, and then, except probably for some unusually per- 
sistent anaemia and debility, and perhaps for some enduring enlarge- 
ment of the cervical glands, may soon be restored to health.. When, 
however, the membranous exudation covers an extensive surface, 
especially if, at the same time, the tonsils and uvula are much swollen, 
the symptoms are much more serious and the duration of the malady 
is prolonged; but even then, if no further complications arise, the 



DIPHTHERIA. 



203 



patient is generally convalescent at the end of ten days or a fortnight. 
There is generally under these circumstances great and increasing 
debility, with anaemia; and not unfrequently the patient who has been 
perfectly sensible all along dies from asthenia or in a fainting fit fol- 
lowing some slight exertion. Occasionally, and more commonly in 
I adults than children, the breath acquires a fetid and distinctly gan- 
! grenous odor — the false membrane at the same time assuming a dirty 
j gray or blackish hue, and a more or less pultaceous consistence, 
j These phenomena are rarely due to actual gangrene, but are generally 
, the result of mere decomposition of the diphtherial exudation. 

This is perhaps the best place to point out that diphtheritic patches 
I not unfrequently make their appearance on the inner surface of the 
| cheeks and on the gums, especially in the neighborhood of the pillars 
! of the fauces, and sometimes at the margins of the lips; and, further, 
: that Bretonneau has described an affection of the gums (frequently 
j associated with distinct faucial diphtheria and evidently of the same 
nature) in which an abundance of rust-colored tartar accumulates 
■ about the necks of the teeth, in association with marginal pellicular 
formations on the gums, and a tendency to the formation of similar 
patches on those parts of the inner surfaces or of the lips and cheeks 
with which the diseased gums come into contact. There is excessive 
fetor of breath and tendency to ffingival haemorrhage. 

2. Extension of the diphtheritic inflammation along the oesophagus 
' is not very common, nor is it attended with any marked special symp- 
toms. Both difficulty and pain in swallowing, and complete and 
unconquerable anorexia, are not unfrequent accompaniments of severe 
cases of simple diphtheria, and hence would not be characteristic of this 
complication, although they would probably attend it. 

3. Diphtheria of the air-passages constitutes one of the most fre- 
quent and at the same time one of the most fatal of the varieties of 
the disease. In some cases, no doubt, the larynx or trachea is the 
primary seat of inflammation and membranous exudation, the fauces 

' remaining healthy. Under these circumstances croupal symptoms 
manifest themselves simultaneously with the first onset of febrile dis- 
turbance, and we have in fact a case of typical croup. In a much 
larger number of cases, however, the laryngeal mischief supervenes on 
ordinary pharyngeal diphtheria, the membranous inflammation extend- 
ing from the one part to the other by continuity. But since in this 
case the preceding affection of the pharynx is often exceedingly slight, 
not to say trivial, and has very likely given little or no positive indi- 

I cation of its presence, the laryngeal sequence is very apt to be assumed 
to be the primary disorder ; and, again, the case falls in with the classical 

! descriptions of croup. In many cases, however, the pharyngeal affec- 

| tion is severe, and has been recognized before the symptoms of croup 

i appear. Here the sequence of events is obvious. 

Thus diphtheritic affections of the larynx and other air-passages 

! may either be secondary to pharyngeal diphtheria, or may commence 
in the larynx or trachea, or possibly even in the bronchial tubes, and 
then either remain limited to these parts or spread upwards to the 
pharynx. Under any circumstances the symptoms resulting from the 



204 



SPECIFIC FEBRILE DISEASES. 



laryngeal or tracheal affection are of the same kind, and of extreme 
gravity. The child (for although membranous croup occurs in adults, 
it is children who mainly suffer) is first attacked with a frequent, short, 
dry, perhaps metallic cough and slight hoarseness of voice — symptoms 
in this affection of the worst omen — even if in other respects he appears, 
as is usually the case, to be fairly well. But soon, some difficulty of 
breathing supervenes, commencing usually in the night. The symp- 
toms now rapidly increase in severity ; the respirations (inspiration 
more than expiration) become noisy, sibilant, stridulous, or metallic, 
especially after an attack of coughing; the voice grows hoarse and 
weak, or fails ; the cough becomes less frequent but more severe — 
paroxysmal, suffocative, harsh, unmusical, wheezy, occasionally but 
not commonly hard and metallic ; and during the paroxysms of cough 
the child tosses itself about, sits up, clutches whatever is near it, 
throws its head back, opens its mouth, dilates its nostrils, and strug- 
gles for breath ; the general surface and the face especially become 
more or less livid, the eyes staring, the expression one of intense 
anxiety. Even now, in the intervals between the paroxysms of cough, 
the child often assumes a fallacious appearance of ease and comfort. 
The breathing may be little quickened, and, unless excited, attended 
with little noise; and the best hopes of recovery may arise. But the 
paroxysms return and increase gradually in frequency and severity; 
until at length the patient, overcome with his exertions and the grad- 
ually increasing asphyxia, passes into a condition of combined coma, 
asphyxia, and prostration, in which he dies. Death takes place some- 
times in a few hours, rarely later than the fourth or fifth day after the 
commencement of symptoms. In adults, however, the course of the 
disease is usually not so acute. During the progress of the attack the 
respirations increase in frequency ; the pulse becomes small, weak, and 
rapid; the surface, especially that of the extremities, cold ; and per- 
spirations break out. Consciousness for the most part remains unim- 
paired almost to the close. The above symptoms are clearly referable 
to the gradual deposition and extension of false membrane in the 
larynx and trachea, and are occasionally relieved by their expulsion 
during the act of coughing. The paroxysmal cough is probably 
chiefly dependent on the occasional blocking up by mucus of the nar- 
rowed rima glottidis or trachea, and on spasm. The extension of the 
false membrane throughout the bronchial tubes, and the supervention 
of lobular pneumonia, are indicated mainly by rapid increase of livid- 
ity and asthenia, increasing imperfection of the respiratory acts, with 
falling in of the lower ribs and intercostal spaces during inspiration, 
inefficiency and feebleness of cough, and suppression of the auscultatory 
phenomena of the lungs. Emphysema of the connective tissue of the 
neck, head, and thoracic parietes, occasionally becomes developed. 

4. Extension of the diphtheritic process to the nose or to the deeper 
tissues of the neck constitutes an essential feature of the so-called 
"malignant" form of diphtheria, and indicates severe concurrent con- 
stitutional poisoning, and an almost certainly fatal issue. Malignant 
diphtheria often comes on with no more severe symptoms than those 
which attend the more common forms of the disease, and even when 



DIPHTHERIA. 



205 



' local signs indicate the course the malady is taking, and the observant 
j physician sees and dreads the impending change, there is frequently 
, nothing in the patient's condition to alarm himself or his friends. The 
.] extension of the disease to the nose is indicated by the presence of 
| catarrhal symptoms, by redness and soreness and discharge of mucus 
I from the nostrils, attended frequently with some degree of epistaxis, 
and, ere long, by a pretty copious flux of bloody ichor. At the same 
\ time the lachrymal ducts become involved, the escape of the lachry- 
| mal secretion by the puncta is arrested, the eyes water, and occasion- 
ally indeed false membranes form on the conjunctivae. On inspection 
I of the anterior or posterior nares the existence of the false membrane 
in the nose will probably be clearly recognized. The extension of the 
I inflammation in depth is shown partly no doubt by progressive en- 
i large in en t of the tonsils and thickening of the soft palate and uvula, 
i but more especially by rapid increase in size of the lymphatic glands 
, in the upper part of the sides and front of the neck, and by infiltration 
' with inflammatory products of the connective and other tissues which 
; intervene between them. By these processes very considerable tume- 
faction is produced ; extravasations of blood and suppurating cavities 
i appear here and there in the substance of the mass ; ulceration or gan- 
grene occasionally takes place at the mucous surface ; and the cutane- 
ous aspect becomes brawny and congested or livid, either uniformly or 
in patches. In malignant cases anaemia and prostration come on with 
! great rapidity ; the pulse becomes rapid, irregular, and extremely 
small and feeble, the surface cold; haemorrhage frequently takes place 
from the various mucous orifices, and petechia? and vibices appear both 
beneath the skin and on the surface and in the substance of internal 
organs ; the patient is restless and occasionally delirious, and death 
results from asthenia. 

5. Although in the vast majority of instances diphtheria commences 
either in the pharynx or in the mucous cavities which communicate 
directly therewith, cases are occasionally met with (especially during 
epidemic outbreaks and amongst the members of infected households) 
in which the diphtheritic inflammation and pellicular formation first 
make their appearance in some other region — occasionally in the vulva 
or vagina, on the glans penis and foreskin, at the anus, in the ex- 
ternal auditory meatus, or on excoriated, or raw cutaneous surfaces. 
The local changes here are identical with those occurring in the more 
usual seats of the disease ; the redness of the affected part is more or 
less vivid and intense, especially in a narrow zone circumscribing the 
adherent pellicle ; the pellicle is white or buff or gray or black, not un- 
' frequently looking like an eschar, and adherent to the surface ; and 
I (when the skin is the part involved) its extension is attended with the 
formation of vesicles at the margins, which run together, and lead to 
the development of spreading excoriations which become presently 
clothed with the enlarging pellicle. Just as in many cases of primary 
pharyngeal diphtheria false membranes appear after awhile on various 
parts of the surface of the body ; so, in the cases now under considera- 
tion, it is not uncommon to find the pharyngeal mucous membrane 
ultimately involved. 



206 



SPECIFIC FEBRILE DISEASES. 



There are two or three important points in relation to diphtheria 
which have been either quite passed over, or only touched upon in the 
foregoing account, but must not be forgotten. The temperature of 
diphtheria is never a characteristic feature, and is rarely high. In some, 
and even in severe cases it scarcely at any time exceeds the normal ; 
generally, however, there is some distinct elevation during the first day 
or two, and occasionally, but more particularly in those cases in which 
the larynx and trachea are implicated, the temperature may rise in the 
course of the disease to 106° or 107° and upwards. The urine in a 
large proportion of cases (one-half or two-thirds, according to different 
observers) becomes albuminous early in the disease, the amount of albu- 
men being sometimes very great. Occasionally, and more especially 
in malignant cases, there is hematuria. Under the microscope will be 
found in the former case hyaline and granular casts, in the latter blood 
more or less modified in character. These conditions of the urine are 
rarely of long duration, and scarcely ever usher in dropsy, uraemia, or 
permanent lesion of the kidneys. Urea is excreted in excessive quan- 
tities during the progress of the disease, and diminishes during conva- 
lescence. Inflammation now and then extends from the throat to the 
ear, and may produce suppuration and other serious lesions in that 
organ, and occasionally spreads from the conjunctiva to the cornea, 
causing opacity, ulceration, and perforation. Delirium is of unusual 
occurrence, and generally forebodes a fatal issue. 

The duration of diphtheria varies widely. When the disease ends 
in convalescence it rarely exceeds a fortnight, and may be as short as 
a week. Death occurs at very different periods, which, however, are 
very much determined by the nature of the lesions inducing it. It may 
take place within the first twenty-four hours, or as late as the end of 
the second week, or at any intermediate period. The causes of death 
have been sufficiently considered. The mortuary rate of the disease is 
very considerable ; it is impossible, however, to form any accurate 
opinion on this point; for while, undoubtedly, in some epidemics 
many mild cases occur of which a large proportion are never even sus- 
pected to be diphtheria, in other epidemics the fatality of the disease is 
frightful.* The most fatal forms of diphtheria are those in which the 
air-passages are affected, especially in children, and those which have 
been spoken of as malignant. 

Diphtheria does not always cease with apparent convalescence. In 
a considerable number of cases morbid phenomena of a totally different 
kind to any which have preceded sooner or later supervene. These 
are affections, for the most part paralytic, of the sensory and motor 
nerves. They sometimes commence with the separation of the false 
membrane, but more commonly come on from a week to a month after 
convalescence seems to have been established. The first and not un- 
frequently the only part affected is the soft palate. The patient, who 
had probably regained his voice and power of swallowing, begins to 
speak with a nasal tone; when he attempts to swallow, a portion of 
his food is apt to pass into the posterior nares ; and on examining the 
throat, the soft palate is found to be pendulous and motionless — mo- 
tionless even when mechanically irritated ; its sensibility is also im- 



I 



DIPHTHERIA. 



207 



paired or annulled. It is worth while pointing out, as showing that 
the palatal paralysis is not the result of local inflammatory changes, 
that it occurs in cases in which no pharyngeal or faucial inflammation 
has been present or in which it has been very slight. The paralysis, 
however, does not necessarily stop here; but gradually (it may be) the 
patient begins to complain of numbness and tingling and loss of power 
! in one or both lower extremities ; soon the upper extremities are attacked 
in the same manner; presently, perhaps, the sensibility of the trunk 
| diminishes and its muscles lose their force; and by degrees the inter- 
costal muscles and the diaphragm fail, and the rectum and bladder 
probably share in the general paresis. Further, the paralytic condi- 
tion commencing in the fauces may spread so as to involve, on the one 
hand, the muscles of mastication, of articulation and of expression, and 
j on the other the larynx, lungs, and heart, and generally the organs to 
j which the vagi are distributed. In addition, complete failure of sexual 
power and appetite often comes on, and more or less affection of the 
organs of sense. There may be loss of smell or of taste, or deafness ; 
l but it is chiefly the eyes that suffer. Squinting and double vision 
occur, and loss of adjusting power by reason of paralysis of the ciliary 
, muscle. Temporary amaurosis sometimes takes place. It is important 
to note that although all the forms of paralysis above specified may 
occur, they rarely all occur in the same individual, and never all at 
the same time. The paralysis, in fact, is progressive, and tends often 
| to get well in one part while it is in progress of extension elsewhere. 
Further, like hysterical paralysis, it often shifts from one part to an- 
other. In place of paralysis, we sometimes meet with hyperesthesia 
and neuralgic pains. Notwithstanding the alarm. which the presence 
of paralysis must necessarily create, the paralytic condition is very 
rarely fatal, and generally ends in perfect recovery in the course of two, 
three, or at the outside four months. 

It is not, however, devoid of danger. When death occurs it is 
mostly in those cases in which the paralysis is rapidly developed and 
extensive, and in which the nerves arising from the medulla oblongata 
and floor of the fourth ventricle are especially implicated. The patient 
may die from inability to swallow food, or from the accidental entrance 
of foreign matters into the larynx, or from gradual failure of the re- 
spiratory acts and consequent apncea or asphyxia, or from enfeeblement 
of the heart's action, which is attended with remarkable slowness, or 
rapidity or irregularity of the pulse and tendency to syncope. Occa- 
sionally in these cases death is due to convulsions or coma. In refer- 
! ence to diphtheritic paralysis M. Duchenne points out that sensation 
! and motion are usually simultaneously affected, but that the impair- 
I ment of sensation tends to preponderate over that of motion. The 
| paralyzed muscles retain their electric contractility, their bulk, and 
I their healthy texture. 

In speaking of diphtherial albuminuria we remarked that it is usu- 
ally one of the early phenomena of the disease. It must be added 
that it sometimes comes on again, or for the first time, during the para- 
lytic stage. 

Morbid Anatomy and Pathology. — The morbid changes which attend 



208 



SPECIFIC FEBRILE DISEASES. 



diphtheria are almost limited to the circumscribed inflammations which 
have been discussed. In most cases the affected parts are congested, 
swollen, and infiltrated with leucocytes and other inflammatory mat- 
ters; and, when the inflammation extends deeply, extravasations of 
blood and foci of suppuration, terminating in distinct abscesses, occa- 
sionally appear. The inflamed surface secretes abundant thin mucus ; 
and soon an opaque layer forms upon it. This increases by additions 
to its under surface and to its edges, and is attached to the subjacent 
mucous membrane, partly by general adhesion, partly by prolongations 
extending into the mucous and other follicles. In the first instance it 
consists only in the inflammatory proliferation of the epithelial cells, 
which become cloudy and are apt from the shrinking of their proto- 
plasm to assume a stellate form, the resulting interstices being proba- 
bly occupied by mucus. This appears to be its permanent condition in 
the pharynx. But in the air-passages a fibrinous exudation takes 
place before long at the surface of the membrana li nutans, between it 
and the modified epithelial layer which it displaces, and coagulating 
there forms a more or less distinctly laminated network of fibres which 
entangle leucocytes but very rarely distinct epithelial elements. Under 
these circumstances the superficial cellular lamina undergoes gradual 
disintegration and disappears, and thus the diphtheritic membrane be- 
comes at length purely fibrinous. Many lowly vegetable organisms 
have, as might be supposed, been detected in it. It is not clear that 
any of them can be justly regarded as specific. Heuter, Oertel, and 
some other observers, however, maintain that the contagium of the 
disease consists in certain forms of bacteria, which they describe as 
existing in great abundance not only in the diphtheritic exudation but 
in the lymphatic spaces of the subjacent corium. The membrane varies 
considerably in thickness and consistence. When very thick, the su- 
perficial parts are often pulpy or flocculent. Their detachment is often 
attended with excoriation, and sometimes with distinct ulceration; and 
occasionally gangrene occurs. We have pointed out the localities in 
which diphtheritic membranes are chiefly formed. It remains to say 
that, when they extend into the nose or into the larynx, they adapt 
themselves accurately to irregularities of surface, and form complete 
solid casts of such diverticula as the sacculi laryngis; and that, when 
they involve the bronchial tubes, they extend sometimes to their finest 
ramifications, forming arborescent laminated casts. It is mainly when 
the air-passages are invaded that collapse of lung and lobular pneu- 
monia take place, and, in children, interlobular emphysema, going on 
(it may be) to the production of general emphysema. The only other 
organs ordinarily presenting obvious morbid changes are the kidneys. 
These may be enlarged, and somewhat pale, and on microscopic exami- 
nation may present granular or fatty deposits in the renal cells, with 
hyaline casts occupying the canals of some of the tubules. In ma- 
lignant cases, besides much more intense local mischief, haemorrhages 
take place beneath the serous and mucous membranes and into the sub- 
stance of the lungs, heart, kidneys, and other organs ; and sometimes 
the muscular tissue of the heart presents granular or fatty changes. 
The blood is sometimes said to be distinctly modified in character; 



i 



DIPHTHERIA. 



209 



but this is certainly not always the fact; and even in the worst cases 
fibrinous clots may be discovered in the cavities of the heart. 

That diphtheria, like the exanthemata, is a specific disease affecting 
the system generally can scarcely be doubted ; its symptoms and prog- 
ress, and especially its paralytic sequelse, all attest the truth of this 
view. There may still, however, be a doubt as to whether the primary 
diphtherial patch, the formation of which attends the first onset of the 
disease, is a localized outcome of the general disorder and analogous 

j therefore to the rash of variola ; or whether it is to be regarded as the 
direct result of inoculation and analogous therefore to the inoculated 
variolous pustule which precedes the general eruption. In what way 
the diphtherial poison induces paralysis is a problem which does not 
at present admit of solution. The lesion, however, whatever its exact 
nature may be, is evanescent, and seems mainly to involve the medulla 

i oblongata and neighboring parts. 

Treatment. — The treatment of diphtheria is a subject of much in- 
terest and importance, and not the less so that great variety of opinion 
has prevailed even in regard to points of vital moment. One of the 
most remarkable features in the disease is its remarkable tendency to 
produce anaemia and exhaustion, and death by asthenia. Such being 
the case, it is scarcely necessary to say that depletory measures cannot 
be adopted without grave risk. Indeed it is now almost universally 
admitted that the general treatment should be directed to the mainte- 

! nance of the bodily powers. To this end, nourishment by appropriate 
kinds of food, and the use of such tonic medicines as the patient can 
bear, must be firmly enforced. The liquid or pulpy foods generally 
administered in acute febrile disorders are suitable here; for medicine 
it is fashionable to prefer the solution of perchloride of iron, and doubt- 
less the preparation is a valuable one ; but there is no reason why other 
preparations of iron should not be. given, or for the avoidance of 
quinine and other vegetable tonics. By some chlorate of potash, or this 
with the addition of small quantities of hydrochloric acid, is strongly 
advocated. For local treatment of the affected mucous membrane 
various agents have been proposed. Breton neau and Trousseau fol- 
lowing him strongly recommend the free application of undilute 
hydrochloric acid; others prefer strong solution of nitrate of silver or 
of bicarbonate of soda, or pure tincture of the perchloride of iron, or 
creosote. Again, other practitioners regard the use of strong caustics 
as useless, if not injurious, and prefer to wash out the throat or to have 

| it gargled with solutions of chlorate of potash, or of alum, or the like; 

: and undoubtedly the administration of ice in small lumps is in many 

' cases very grateful. Remedies to the nose must be applied either in 

i the fluid form by means of a syringe or nasal douche, or as a powder 
by insufflation. The larynx must be treated, either by insufflation, by 
"swabbing," or by the use of the vaporizing apparatus under the 
guidance of the laryngoscope. Emetics, which were formerly and are 
still often given for their supposed specific effects on inflammations of 
the respiratory mucous membrane, have been regarded as remedies of 
the utmost importance in croup, and therefore in all cases in which the 
diphtherial membrane tends to pass into the larynx. They are indeed 

14 

I 



210 



SPECIFIC FEBRILE DISEASES. 



sometimes useful, but chiefly if not solely by the mechanical influence 
of the act of vomiting which they induce, in promoting the expulsion 
from the larynx and trachea of the mucus, and even of the false mem- 
brane which obstructs them. They must, therefore, be regarded as 
local remedies merely. Of emetics it is best to give those that act 
rapidly and without inducing much depression; for these reasons, 
large doses of ipecacuanha or of sulphate of copper are preferable to 
antimony. 

As soon as distinct implication of the mucous membrane of the 
larynx or trachea occurs, the question of the performance of tracheotomy 
will necessarily and properly present itself. The extreme fatality of 
croup if left to itself, the little influence which drugs exert over its 
progress, and the fact that death is in the great majority of cases only 
due to the affection of the larynx and trachea, render in many cases 
the opening of the trachea our only hope. It is doubtless generally 
difficult to decide at what moment the operation becomes imperative. 
Here the physician must do what he thinks best according to his own 
judgment, bearing in mind, however, that it is much better to perform 
the operation too early than too late, and that he ought not to be de- 
terred from doing it by the supervention of one of those deceptive inter- 
vals of calm and tranquil breathing, which are so common even while 
the disease is hastening to its fatal issue. Further, it is better to 
operate even when life seems ebbing away, or the patient is moribund, 
and in the face of every discouragement, than to let him die suffocated 
before one's eyes without making an effort to save him. Trousseau's 
vast experience of this treatment of croup gives an average of one suc- 
cessful operation out of four; he points out, however, that tracheotomy 
on children under two is almost never successful. Other writers 
(chiefly foreign) record results at least equally successful. 

In the treatment of convalescence, and in that of the consecutive 
paralysis, all efforts should be directed to improve the general health 
of the patient and to give him strength. With these objects, change 
of air, tonics (especially quinine and iron), good diet, and a fair pro- 
portion of stimulants are most important. Other agents may be ser- 
viceable in promoting the cure of the paralysis, especially strychnia, 
galvanism, and friction. 

Lastly, looking to the established fact that breaches of the cutaneous 
surface have a great aptitude to become the seat of diphtherial inflam- 
mation, it should be regarded as a fundamental rule never to employ 
blisters or other remedies calculated to produce sores. 



ENTERIC FEVER. {Typhoid Fever. Abdominal Typhus) 

Definition. — A febrile disorder, characterized by an inflammatory 
affection of the agminated and solitary glands of the intestines, gastro- 
intestinal disturbance, and a peculiar rash. 

Causation and History. — Enteric fever is a disease of world-wide 



I 



ENTERIC FEVER. 



211 



| prevalence, occurring for the most part in an endemic form, but occa- 
sionally assuming the proportions and the behavior of a genuine 
epidemic. It seems to have no special connection either with over- 
crowding, poverty, or ill-health, and indeed to attack the denizens of 

I town and country, rich and poor, healthy and ailing, with singular 
impartiality. Sex is without influence over it ; but children and young 
persons are much more liable to it than adults, and these than such as 
are of advanced age. Dr. Murchison's investigations show that more 

| than half the total number of cases admitted into the London Fever 
Hospital during ten years occurred in persons between the ages of fif- 
teen and twenty-five; more than a fourth in persons under fifteen ; 
one-tenth in persons between twenty-five and thirty; and that from the 
latter age onwards the numbers rapidly diminished. Considering, 
however, how few children attacked with enteric fever are likely to 
become hospital patients, it seems not improbable that the tendency to 
contract the disease is pretty nearly equal at all ages up to about 
twenty-five, and that from that epoch it rapidly and uniformly dimin- 
ishes. Undoubted cases have been recorded at various ages between 
seventy and ninety. Dr. Murchison also shows, from the records of 
the Fever Hospital, that enteric fever prevails chiefly in October, 
November, September, and August, and that it is at its minimum in 
April, May, February, and March ; and he confirms the general belief 
that its prevalence is augmented by excessive heat of weather, and 

! diminished by continuous low temperature. There is reason to believe 
that persons newly arrived in districts in which enteric fever is en- 
demic are more likely to take it than those who have resided there for 
some time. 

The confusion which prevailed up to within a recent period in regard 
to typhus and enteric fevers rendered any exact knowledge of their 
causation impossible. Since, however, they have been recognized as 
distinct and specific diseases, much light has been thrown upon the 
subject. It has been proved, indeed, apparently beyond all cavil, that 
enteric fever is par excellence the fever of fecal decomposition ; that it 
occurs only among those who are exposed to the influences of defective 
drains or foul and overflowing cesspools, especially when these are so 
situated as to pour forth their fetid gases into the interior of houses, or 
to contaminate by their emanations, their soakage, or their leakage, 
water and other articles used for food. In opposition to this view, it 
has been asserted that persons who work in the sewers are never attacked 
! with enteric fever; but, even if this were the fact (which it is not), it 
would weigh nothing against the positive evidence on the other side, 
which has been furnished of late years by repeated scientific investiga- 
i tions into the causes and circumstances of local outbreaks of the disease 
I all over the country. The whole subject of its a?tiology, however, is not 
exhausted in the above remarks. It is admitted by probably all phy- 
| sicians that enteric fever is not, in the usual sense of the term, conta- 
j gious ; that it is not conveyed from one person to another person by 
the touch or by the breath ; and that attendants on the sick rarely if 
ever take the disease from them ; yet it is quite certain that the immi- 
gration of a patient, suffering from enteric fever, into an uninfected 



! 



212 



SPECIFIC FEBRILE DISEASES. 



locality not unfrequently leads to an outbreak there of greater or less 
severity. We have pointed out that it seems not to escape with the 
breath, or from the cutaneous surface ; and, it must be added, that if 
it escapes with the faeces in an active form it is difficult to understand 
how the nurses, and other persons brought into relation with the sick, 
so constantly escape infection. It has been observed, however, over 
and over again, that the fasces, which are probably at first wholly in- 
effective, become, in the course of putrefaction, virulent in a high de- 
gree, and impart their infectious properties largely to the contents of 
cesspools and sewers, and thence to well and other waters, with which 
the former happen to communicate. In many cases indeed, the source 
of an enteric-fever outbreak has been distinctly traced to the water of a 
well, into which there has been percolation from a neighboring cesspool 
recently contaminated with the evacuations of a patient suffering from 
that fever ; and occasionally also, groups of cases seem to have been 
distinctly referable to body-linen and bedclothes befouled with typhoid 
evacuations, which have been allowed to accumulate and remain un- 
washed. It seems clear, therefore, that persons suffering from enteric 
fever discharge in their fecal evacuations (as do cholera patients) some 
specific but at the time innocuous organized substance; which, after its 
escape from the body, and under suitable circumstances, increases and 
at the same time becomes virulent, diffusing itself throughout the fluid 
media into which it gains access, and imparting to them its specific 
properties. The question then arises, does the specific poison of this 
disease, which is certainly generated from the stools of patients suffering 
from it, also arise spontaneously, or rather independently of such stools? 
The question is by no means easy to solve. Dr. Murchison espe- 
cially argues strongly in favor of its origin independently of the disease 
which it generates. Dr. Budd and others argue with equal vehemence 
in favor of the opposite hypothesis. We confess that we incline strongly 
to the latter view ; and, in accordance with it, are disposed at present 
to regard the essential cause of enteric fever not as a mere inorganic or 
even organic result of decomposition, but (like other contagia) as an 
organized living particle which has special endowments and unlimited 
powers of multiplication ; not as the product of healthy bowels or of 
ordinary decomposing ordure, but as a specific virus yielded by the 
bowels of patients suffering from enteric fever, and probably by them 
alone. 1 A further question here presents itself, namely, by what chan- 
nel does the virus gain admission into the system ? It is certain that in 
many cases it is received into the alimentary canal ; it is thus that the 
disease is imparted by contaminated water, and by milk to which con- 
taminated water has been added. It is generally believed also that it 
may be inhaled with the breath, and that it is thus that the effluvia of 
cesspools and drains act in producing the disease. On the whole, there 
is reason to suspect that the virus in all cases enters the system at the 
surface of the alimentary mucous membrane, and that the intestinal 
lesions are to be regarded as points of inoculation. 

One attack of enteric fever is believed to confer immunity against 

1 See Dr. Klein's observations in reference to this subject quoted on page 136. 



ENTERIC FEVER. 



213 



subsequent attacks. If, however, this be so, the immunity is much less 
perfect than in the case of the infectious fevers generally ; many second 
attacks have been recorded ; and, moreover, true relapses are far more 
common than in other allied specific disorders. 

Symptoms and Progress. — The mode of attack and the initiatory 
I symptoms of enteric fever present great variety. In exceptional cases 
I its invasion is as sudden and well-marked as that of typhus, the symp- 
j toms moreover resembling those of that disease. Much more eom- 
I monly, however, it comes on so insidiously, with undefinable feelings of 
i malaise, or slight feverish ness, or failure of appetite and strength, or 
some degree of gastro-intestinal disturbance, extending over some days, 
. that the patient is quite unable to fix the date of the commencement of 
his illness. During the early period of enteric fever, the patient suffers 
in a greater or less degree from the following symptoms: irregular 
chills and flushes of heat; increased frequency of pulse and elevation 
of temperature; lassitude, and aching in the limbs ; thirst and loss of 
appetite, with morbid redness or coating of the tongue ; and headache 
or heaviness of the head, with tendency perhaps to drowsiness by day, 
to wakefulness, restlessness, and to dream at night-time. Vomiting 
i and diarrhoea, with abdominal pain, and tenderness in the csecal 
region, are generally associated with the above symptoms, and, though 
sometimes absent, are often the very earliest and generally the most 
striking of the phenomena which attend the earlier period of the dis- 
ease. During the first week of the fever, although the symptoms 
gradually increase in severity, the patient is very often not confined to 
his bed. At the beginning of the second week, however, unless the 
case be exceptional either in its mildness or its intensity, the symptoms 
become more fully developed and assume a more characteristic aspect. 
The fever reaches its acme ; the skin is generally hot and dry, but 
liable to break out in perspirations ; the pulse increases still in fre- 
quency, as also do the respirations, and not ^infrequently there is some 
degree of cough ; the tongue may continue clean or become coated with 
a moist fur, but generally, whether coated or clean, it tends to become 
dry and to present cracks, mostly transversal, upon the dorsum ; the 
vomiting has very probably subsided, but thirst and anorexia continue, 
and there may be some difficulty in swallowing and speaking in con- 
| sequence of soreness of the throat; the patient sleeps badly; and 
j occasionally, but by no means in all cases, delirium comes on, especially 
i at night-time and between waking and sleeping. It is about this time, 
j too, that the rash which is peculiar to the disease first makes its ap- 
j pearance. It consists in lenticular rose-colored spots, distinctly elevated 
and sensible to touch, disappearing on pressure, and varying when 
! fully formed from half a line to a line and a half in diameter. 
Though generally rising above the general level in the form of seg- 
ments of spheres, they occasionally become vesicular in the centre and 
thus more or less distinctly acuminated. They are rarely numerous, 
| and always appear in successive crops — those of each crop attaining 
their full development, and disappearing, in the course of two, three, 
or four days. Thus, spots of various ages are generally present and 
intermingled at one and the same time. In perhaps one-fourth of the 



i 



214 



SPECIFIC FEBRILE DISEASES. 



total number of cases no spots are ever discovered ; and in the re- 
mainder their number may vary from a dozen or less up to many 
hundreds. They are chiefly developed on the chest, abdomen, and 
back ; but occasionally are observed on the face and extremities. At 
this time too the intestinal symptoms usually become pronounced; 
the abdomen is more or less tumid; tenderness and pain manifest 
themselves more distinctly in the right iliac region, where also on 
pressure gurgling may be detected ; and the bowels become loose — 
open three, four, or a dozen times a day, and discharging liquid yellow 
stools which have been likened, not unaptly, to pea soup. From the 
condition above described the patient may gradually recover. But in 
a large proportion of cases he passes, in the course of the second week 
(probably towards its close), into a typhoid condition. The elevation 
of temperature continues; the rash still comes out; the diarrhoea per- 
sists ; the tongue becomes dry and brown and traversed by deep 
fissures, the lips and teeth covered with sordes, the pulse quicker and 
more feeble ; the general prostration increases ; complaints of headache 
and pain cease ; the mind grows dull and apathetic; drowsiness and 
delirium (sometimes violent, sometimes busy, sometimes muttering) 
supervene; and bed-sores tend to form. Blood, in greater or less 
quantities, is now not unfreqnently passed with the stools. Finally, if 
the case be going on unfavorably, tremors, subsultus and involuntary 
passage of the evacuations take place, the somnolence or delirium 
passes into coma, and death ensues. If, on the other hand, the case 
be likely to do favorably, convalescence commences usually in the 
course of the third or fourth week. The change is in general quite 
gradual. The fever slowly abates, the pulse falls, the cerebral symp- 
toms pass away, the tongue cleans, the appetite reappears, the diarrhoea 
ceases, and the strength gradually returns. The progress of convales- 
cence is, however, always slow, and the patient often does not regain 
his former health until after the lapse of many months. Occasionally, 
when convalescence seems to be fairly established, a relapse takes 
place, attended with the rash and all the other symptoms and phenom- 
ena which characterized the original attack. 

The foregoing account applies, for the most part, fairly well to the 
ordinary run of well-marked, uncomplicated cases of enteric fever. 
No disease, however, is attended with greater variety of symptoms, or 
presents more frequent and greater departures from the typical charac- 
ter. It is desirable, therefore, to discuss briefly the various phenomena 
of the disease, and its varieties. 

The pulse varies greatly in frequency ; occasionally, in very mild 
cases, it scarcely exceeds the normal throughout the whole course of 
the illness. In other cases, however, it mounts (in dependence very 
much on the severity of the case) to 90 or 100, and from this to 120, 
140, or more, and becomes very feeble. It is generally quicker in 
the evening than the morning, and in the typhoid stage than in the 
earlier period. Other things being equal, rapidity of pulse implies 
severity of attack. It is curious, however, that even during the pres- 
ence of marked fever the pulse may at times sink below 50 or 60. In 
one of Dr. Murchison's cases it fell to 37. 



ENTERIC FEVER. 



215 



The respirations are generally more or less accelerated, especially 
with the advance of the fever, and not iinfrequently some little cough 
is present. These symptoms are necessarily greatly aggravated when 
(as not iinfrequently happens) bronchitis or pneumonia becomes devel- 
oped. Then the surface is apt to become dusky, and the local signs 
of the complication manifest themselves. 

The character of the tongue varies. In some cases this organ re- 
mains almost normal throughout the illness, or is merely a little redder 
and drier than natural, or presents the slightest possible increase of 
epithelium only. More commonly it is covered, except at the mar- 
gins, with a whitey-brown fur which tends to become dry, or it pre- 
sents a dry, glazed, morbidly red character, and in either case is apt to 
present transverse cracks which are often of considerable depth. The 
throat is not iinfrequently congested and sore, and there may even be 
inflammation of the tonsils at an early period. Sickness is one of the 
most common of all the initiatory symptoms, and is sometimes exceed- 
ingly severe. It may last through at the whole of the illness. Thirst 
and loss of appetite are almost invariable. Diarrhoea is rarely absent, 
and is often very severe. Not iinfrequently it is present from the be- 
ginning ; in many cases it does not come on till the second week, or 
even later, but occasionally there is constipation throughout, or the 
patient has an occasional loose stool only. The motions have usually 
the appearance and consistence of pea soup, and are alkaline and often 
offensive. In the course of the second, third, or fourth week, they may 
contain blood. The progress of the fever is generally attended with 
some abdominal pain, with tenderness and gurgling in the right iliac 
fossa, and more or less flatulent distension of the belly. 

In the early part of the disease the urine is scanty, dark-colored, 
and of high specific gravity ; later on it becomes pale and copious, and 
its specific gravity falls. There is almost always a large increase in 
the amount of urea and uric acid, especially at the commencement, and 
the chlorides are diminished. Albumen is not present in more than 
one-third of the total number of cases, and occurs for the most part in 
very small quantity, and rarely before the third week. 

The skin, though for the most part dry, is apt to become moist, 
especially in the morning, and during the latter part of the second or 
in the third week profuse perspirations may occur. The cheeks, espe- 
cially after meals, or during the febrile exacerbations, are often flushed. 
The rash, which has been already described, continues by successive 
outbreaks for one, two, or three weeks. During convalescence perspi- 
rations are often very copious, and sudamina generally appear on the 
chest. 

The fever, as indicated both by the thermometer and by symptoms, 
is always of a remittent character, presenting morning remissions and 
evening exacerbations. The temperature begins to rise about noon, 
and attains its maximum between 7 p.m. and midnight. After mid- 
night it begins to fall, the lowest point being usually attained between 
6 and 8 a.m. In uncomplicated cases these daily remissions are almost 
invariable, the difference between the morning and evening tempera- 
ture varying from one to two or three degrees, or even more. The rise 



216 



SPECIFIC FEBRILE DISEASES. 



begins from the first day of illness, and gradually increases by daily 
waves, until, on the fourth or fifth day, or about the end of the first 
week, it attains its greatest elevation, which varies in different cases I 
between 104° and 106°. From this period, up to about the twelfth . 
day, there is but little change. Then, if the case be mild, the morn- j 
ing falls become lower, and of longer duration, to be followed shortly 
by corresponding falls in the evening, and gradually, as convalescence 
becomes established, the morning and evening temperatures approxi- 
mate and attain the normal level, or even sink below it. If, on the 
other hand, the case be severe, and the commencement of convales- 
cence be delayed, the temperature still continues high, and the morn- 
ing remissions become often less marked than they had been. Again, 
if in the course of the disease serious complications arise, the usual 
course of the thermal variations is modified. Profuse diarrhoea, epis- 
taxis, or intestinal haemorrhage, causes the temperature to fall ; as also 
does the condition of collapse, however produced. Pneumonia causes 
the temperature to rise, and modifies its diurnal variations. Sometimes 
it rises before death to 108°, or even to 110.3°, independently of com- 
plications (Wunderlich). 

As regards the organs of sense, singing in the ears and deafness are 
not uncommon; the conjunctivae are rarely congested, the pupils usually 
dilated ; epistaxis is of frequent occurrence. Most patients complain 
of giddiness and headache at the beginning of the disease, and of more 
or less pain and sense of lassitude in the limbs. There is frequently 
wakefulness at night; sometimes, on the other hand, there is somno- 
lence, and this not unfrequently precedes delirium. Delirium is not 
invariable; in many cases it never occurs; in many it is slight, and 
shows itself only between waking and sleeping. In severe cases it 
comes on usually about the middle or end of the second week, and is 
then apt to vary in character and duration. It may present all the 
varieties of the delirium of typhus, but, as Dr. Murchison remarks, it 
is more frequently of the violent and noisy kind than in that disease. 
In rare cases the invasion of the fever is attended with maniacal ex- 
citement. Coma occasionally supervenes before death. Convulsions 
are not usual, but are more common in children than adults. They 
generally come on late, and frequently prove fatal. Muscular weak- 
ness is always present, but is not so marked as in typhus ; neverthe- 
less, in the later stages of severe cases, tremors and subsultus are com- 
mon. Occasionally there is muscular rigidity. 

Enteric fever presents itself in many forms, and has been, and still 
is, frequently confounded with other diseases. It is especially impor- 
tant to know that, for the most part, cases of so-called " infantile remit- 
tent fever," " worm fever/ 7 " gastric fever/' and " bilious fever," are 
cases of this affection. ' In the mildest form of the disease the patient 
perhaps complains only of slight feverishness and weakness, with loss 
of appetite, and more or less diarrhoea or irregularity of the bowels, 
and continues perhaps his ordinary avocations, or at all events does 
not take to his bed, and, if no complication supervenes, recovers at the 
end of three or four weeks. In other cases the disease is much more 
severe in character, and its progress is more or less distinctly in accord- 



ENTERIC FEVER. 



217 



I ance with the account we have already given. The attack is one of 
well-marked enteric fever, but varies according to the relative promi- 
1 nence of certain of the symptoms, such, for example, as vomiting, 
! diarrhoea, thoracic complication, haemorrhage, and delirium. In other 
! cases again, the attack is from the beginning of exceptional severity, 
| and, as in analogous cases of scarlet fever and other like affections, the 
! patient dies, poisoned apparently, and in a state of collapse, within the 
first week, sometimes on the first or second day. 

Much of the danger which attends enteric fever depends on the com- 
I plications which arise in its progress. The most important of these 
I are intestinal haemorrhage, perforation of the bowels with peritonitis, 
I and pneumonia or bronchitis. 

It has been already pointed out that intestinal haemorrhage is not 
! unfrequent. It may occur at almost any period of the disease, but is 
most common from the middle or end of the second week to the end of 
the fourth. It may be due (in cases where there is a general haemor- 
rhagic tendency) to oozing from the mucous surface ; but far more 
I commonly it takes place from the surfaces or edges of the intestinal 
ulcers. It has no necessary connection with the extent or the size of 
ulcers present, or with the presence or absence of diarrhoea, or indeed 
with the mildness or severity of the patient's previous symptoms. The 
haemorrhage may be very scanty, or so copious as to cause speedy death 
by syncope ; and the blood which escapes may be fluid or clotted, 
black or of the normal color of blood. 

Peritonitis is one of the most frequent causes of death in enteric 
fever, and, like intestinal haemorrhage, has no necessary dependence 
either on the severity of the case or the urgency of diarrhoea. In the 
vast majority of cases it is due to perforation of the bowel in the floor 
of one of the intestinal ulcers, and is, therefore, sudden and unex- 
pected in its onset. Not unfreqnently it occurs in patients who have 
never taken to their beds ; who are then seized, without warning, with 
intense abdominal pain, tenderness and distension, together with vom- 
iting, collapse, thoracic respiration, and other indications of acute 
peritonitis. In such cases the nature of the complication is manifest. 
When, however, perforation takes place in patients who are already in 
a typhoid condition, the indications are very apt to be overlooked. 
Yet, even in these cases, there may be more or less evident abdominal 
I pain and other local signs of peritoneal inflammation ; but very often 
the diagnosis must be made to rest mainly on the sudden supervention 
of collapse, with fall then rise of temperature, increased rapidity and 
feebleness of pulse, hurried and thoracic respiration, duskiness of sur- 
; face, copious perspirations and flatulent distension of the abdomen, 
j Indeed it may be said generally that the sudden appearance in the 
| course of enteric fever of symptoms of intense collapse, even when no 
i direct evidence of abdominal inflammation is present, points to the 
occurrence of perforation. Perforation of the bowel may occur in 
I patients of all ages, but is more common in males than in females. It 
cannot take place until ulceration has commenced, and, as might be 
supposed, is more common when ulceration is advanced than when it 
is beginning. Hence, although it occasionally happens during the 

ll 



218 



SPECIFIC FEBRILE DISEASES. 



second week (more especially towards its close), it is much more com- 
mon during the third, fourth, and fifth weeks; and, indeed, all risk 
has not ceased until the expiration of two or three months. It not I 
uncommonly happens, therefore, during the period of convalescence ; ! 
and occasionally after apparently complete restoration of health. | 
Death almost invariably follows this lesion ; and generally occurs 
within a couple of days, sometimes in the course of a few hours. But 
occasionally life is prolonged for a week or two ; in which case the I 
peritonitis becomes circumscribed and an abscess forms. A few cases 
of recovery after the evacuation of such an abscess have been recorded. 
Dr. Murchison calculates that no less than one-fifth of the total num- 
ber of deaths from enteric fever are due to perforation of the bowels. 

Bronchitis is often present in a slight degree ; but occasionally it 
becomes severe, and may be so at any stage of the fever. The symp- 
toms of bronchitis are then added to those of the primary disease and 
mask them. So pneumonia, mainly lobular pneumonia, may creep on 
insidiously at any time, but most commonly occurs during the third 
or fourth week. It is usually connected with the hypostatic congestion 
of the lungs which is generally present in a greater or less degree, and 
hence occupies mainly the back and basal portions of one or both lungs, 
and may fail to be detected unless the attention of the physician is 
specially attracted by the presence of symptoms indicating thoracic 
mischief. Pleurisy ending in empyema is also not unfrequent. 

Many complications and sequelae are described besides the above; 
but they are, for the most part, unimportant or rare. We will enu- 
merate a few of the more important. Ulceration of the larynx or 
trachea is described by various good observers, but is certainly very 
uncommon. Thrombosis of the veins, leading to oedema, is not unfre- \ 
quent, especially in connection with the lower extremities. Bed-sores j 
are very apt to form on the sacrum and other parts which are exposed j 
to pressure or to irritation ; but, independently of these, gangrene oc- j 
casionally attacks the mouth (noma), ears, penis, vulva, feet, cornese, j 
and especially parts to which blisters have been applied, or which are j 
already inflamed from other causes. Imbecility, mania, and other 
mental disorders occasionally follow on enteric fever, as they do on 
other affections attended with extreme exhaustion. So also does pro- 
longed marasmus, or the development of tuberculosis. The existence j 
of pregnancy is not very formidable. Abortion not unfrequently takes \ 
place. But neither pregnancy nor abortion appears to interfere ma- 1 
terially with the prospect of recovery. 

There is probably no other disease in which death threatens from so 
many quarters, and in which it may occur at such diverse and unex- 
pected times. It is due immediately either to asthenia, asphyxia, or 
coma, or to combinations of these. It may occur early in the disease, 
mainly from the intensity of the attack, in which case there is generally 
more or less pulmonary congestion. It more commonly, however, 
occurs at a later period, either from pneumonia or other pulmonary | 
complication, from perforation and peritonitis, from intestinal hsemor- | 
rhage, or from coma coming on in the course of typhoid symptoms. \ 
And, again, it may ensue, during the period of convalescence, from 

- 

j 



ENTERIC FEVER. 



219 



some of the complications which have been enumerated or from sheer 
exhaustion. Enteric fever in hospital practice is fatal in about the 
same proportion as typhus — at the rate, namely, of about 15 or 16 per 
cent. But when we consider how large a number of mild cases occur, 
which are not only never admitted into hospital, but are not even recog- 
nized, it becomes obvious that the proportion of total deaths to total 
attacks must be much smaller than the above figures imply. The per- 
centage mortality varies little with age ; but, on the whole, the sta- 
tistics of the London Fever Hospital show that the death rate is less 
below the age of 20 than in the later periods of life, and that it is 
highest in patients above 50. 

It is not generally difficult to distinguish between a case of enteric 
fever and one of typhus. The main clinical distinctions are furnished, 
first, by the mode of invasion, which is generally sudden in typhus, 
insidious in typhoid; second, by the rash, which is abundant, general, 
and of nearly simultaneous origin in typhus, scanty and coming out in 
successive crops in typhoid; third, by the abdominal symptoms, which 
in typhus are usually vague, but in typhoid comprise the discharge of 
liquid yellow stools, intestinal hemorrhage, pains and tenderness in the 
csecal region, and tympanites; fourth, by the temperature, which does 
not present in typhus the regular diurnal variations which are so char- 
acteristic of typhoid; and, fifth, by the mode of convalescence, which 
is by crisis and rapid in typhus, but slow and followed by long-con- 
tinued debility in typhoid. Many other distinctions of secondary value 
might be readily adduced. But it must not be forgotten that occasion- 
ally all may fail us, and that the discovery of the typical intestinal 
lesions after death may alone reveal the nature of the case which has 
been under treatment. 

Morbid Anatomy. — Enteric fever is always attended with character- 
istic anatomical lesions, affecting the solitary and agminated glands of 
the bowels and the mesenteric glands in direct relation with them. 
These lesions consist in an apparently simple hyperplasia of the gland- 
ular elements, in virtue of which the organs undergo rapid enlargement, 
and then either slowly subside, reverting to their normal condition, or 
undergo softening or suppuration, ulceration or gangrene. Under the 
microscope the lymphatic corpuscles are found to be increased in num- 
ber; and frequently hypertrophied cells containing groups of small 
cells in their interior may be discovered; later on the cells become 
granular and fatty and break down into a granular detritus. The 

j morbid process appears to begin with the first symptoms of the pa- 

j tient's illness ; at all events, it has been found well advanced in those 

] who have died during the first few days. 

The intestinal lesions are in many cases limited almost entirely to 
the agminated glands, of which sometimes two or three only, sometimes 

i the whole number, are involved. These become gradually hypertro- 
phied until they acquire a thickness which varies from a line to j- inch, 

| forming oval plates which present a more or less tumid margin, a sur- 
face w 7 hich is sometimes reticulated or foveated but oftener more or less 
mammillated and smooth, and a consistence which is sometimes softer 
but more often denser, though more friable, than natural. They attain 

I 



220 



SPECIFIC FEBRILE DISEASES. 



their full development generally by the ninth or tenth clay — sometimes 
a day or two earlier, sometimes a day or two later. And then they 
either undergo slow resolution or proceed to ulceration. The latter 
process may commence from the surface at numerous points, and thence 
gradually invade and destroy the whole of the diseased mass; or, as 
more frequently happens, the patch sloughs at once in the whole or the 
greater part of its extent. The resulting slough, which soon assumes a 
yellow or brown hue from the imbibition of bile-pigment, becomes soft, 
spongy, tumid, and separated by a line of demarcation from the still 
living tissues, and after a short time separates either in mass or in suc- 
cessive fragments. The separation of the slough generally occurs be- 
tween the fourteenth and twenty-first day, but may not be fully com- 
pleted for another week. The ulcer which results from either of the 
above processes varies in its character according to circumstances. Its 
form is oval, round, or sinuous, according as it involves the whole or a 
portion of a patch. Its margins are often thick and vertical, as if made 
by a punch, and more or less congested. Its floor is pretty smooth and 
formed of the submucous tissue. Sometimes, however, the edges are 
more or less extensively undermined, and then perhaps intensely con- 
gested, and the floor irregularly excavated and flocculent, and formed 
partly of the exposed muscular coat, partly, it may be, of the peritoneal 
membrane only. The cicatrization of the ulcers does not usually begin 
before the end of the third week, and is probably usually completed in 
about a couple of weeks more. But the process may be delayed either 
from mere sluggishness, or by a kind of phagedenic extension of the 
ulcer, or by other circumstances, and hence may not be completed under 
two or three months. The cicatrices rarely if ever lead to serious con- 
traction, 

The typhoid process as it affects the solitary glands is precisely 
similar, excepting that the resulting tumors are much more numerous 
and much smaller — generally about the size of half a pea; and that, 
on the one hand resolution without ulceration is more common, and on 
the other the sloughs and ulcers which form are of insignificant dimen- 
sions and tend to heal more rapidly. 

The morbid process, whether it be confined to the agminated glands 
or involve the solitary glands as well, is always most extensive and most 
advanced in the ileum immediately above the ileo-csecal orifice ; whence 
it gradually diminishes upwards. The solitary glands are rarely affected 
to a greater distance than two or three feet above the valve ; Peyer's 
patches rarely above the lower half of the ileum. The disease impli- 
cates the solitary glands of the large intestine in about one-third of 
the cases, and is always most advanced in the cascurn, rarely extending 
below the ascending colon. Perforation takes place only in those ulcers 
which have already perforated the muscular wall. When the floor is 
thus formed of peritoneum only, it sometimes happens that local peri- 
tonitis occurs and causes adhesion between the affected portion of bowel 
and some neighboring organ, and thus averts the impending catastro- 
phe. The perforation of the bowel may, in some cases, be due to the 
forcible separation of such adhesions ; but more commonly, probably, 
it is the result of the simple accidental laceration of the more or less 



ENTERIC FEVER. 



221 



softened and unsupported serous covering. It occurs in the great 
majority of cases in the lower two feet of the ileum ; but it has been 
met with at least six feet above the ileo-csecal valve. Rarely, it has 
occurred in the csecal appendage or in the colon. The peritonitis 
which results is always in the first instance general ; but not unfre- 
quently when the rupture is small and but little fecal matter has 
escaped, this latter and the attending suppuration are found after death 
to be strictly confined by adhesions to a very limited space. It is this 
tendency to limitation which gives an element of hope in the treatment 
of these cases, and to which the very few recorded recoveries after per- 
foration are due. Sometimes the laceration is so extensive that large 
quantities of fecal matter are discharged into the peritoneal cavity. 

The mesenteric glands, especially those connected with the lower 
part of the ileum, enlarge from the beginning with Peyer's patches ; 
they attain sometimes the size of a walnut, become soft and vascular, 
and at the end of either ten days or a fortnight undergo resolution, or 
soften, or suppurate. Under the latter circumstances they not unfre- 
quently eventually dry up; sometimes, however, they induce perito- 
nitis either by extension of inflammation, or by rupture into the serous 
cavity. Most other lesions in enteric fever, such as bronchitis, pneu- 
monia, and pleurisy, have no specific characters, and need no descrip- 
tion. The spleen, however, is enlarged and congested ; and it may be 
added that when the patient dies during the ulcerative stage of the 
fever, the contents of the bowels are generally peasoup-like, and the 
large intestines inflated with gas. 

Treatment. — Knowing as we now do the source from whence the 
contagium of enteric fever enters the system, it becomes our duty, nor 
is it difficult, to adopt suitable precautionary measures both against 
the contamination of water and of atmospheric air, and against the 
exposure of persons to the influence of media thus contaminated. 
Whenever typhoid patients are under treatment their evacuations 
should be disinfected with carbolic acid, Condy's fluid, or chloride of 
lime, before they are emptied into the sewer or the cesspool ; and all 
articles of dress soiled by such evacuations should be similarly disin- 
fected and washed. Water-closets and drains should be kept sound, 
clean, well flushed, and ventilated, and all communications between 
them and the interior of the house cut off by efficient traps. No water 
should be used for drinking or culinary purposes which has been ex- 
posed to sewage-contamination ; hence the water of superficial wells, 
especially if these be near cesspools or sewers, should be looked upon 
with grave suspicion; as also should the water derived from streams or 
ponds receiving drainage, and that from cisterns or butts communica- 
ting by waste-pipes with closet-drains. If such waters must be drunk, 
they should first be boiled and filtered. It must not be forgotten that 
milk, from the presence of water which has been fraudulently or other- 
wise added to it, has on several occasions been the vehicle for the com- 
munication of the disease. 

Many remedies have been employed for the cure of enteric fever ; 
amongst others mineral acids, antiseptics — such as chlorine, hyposul- 
phites, Carbolic acid and creosote — and emetics ; other remedies, again, 



222 



SPECIFIC FEBRILE DISEASES. 



have been used with the special object of reducing the fever — such are 
quinine in large doses (10 or 15 grains), actual refrigeration, and bleed- 
ing. The last practice has properly fallen into desuetude. The use 
of cold has been proved to be frequently beneficial, especially in cases 
in which the temperature reaches or exceeds 104° ; it is best applied 
by means of baths, the temperature of which to begin with should be 
10 degrees or more below that of the body, and then gradually reduced 
to about 68°, immersion being continued for about half an hour or until 
the patient's temperature, as ascertained in the mouth or rectum, has 
become sensibly reduced, or shivering comes on ; but cold or tepid 
sponging is also serviceable. Our chief aims, however, in the treat- 
ment of this disease must consist in the guarding against, and the pre- 
vention of, the many sources of danger which attend it, and in relieving 
symptoms as they arise. The condition of the bowels must be carefully 
watched, and under no circumstances must drastic purgatives be em- 
ployed. There is no harm, perhaps, in giving a mild laxative, such 
as castor oil in small doses, or rhubarb, during the first week of the 
disease and before ulceration has taken place; but even then it is gen- 
erally sufficient, and on the whole certainly more safe, to employ 
enemata. Subsequently, enemata only should be resorted to. When 
diarrhoea is present it should be restrained either by the use of tannic 
acid, lead and opium, sulphuric acid, the compound kino powder, or 
some such remedy, or by that of opium or morphia suppositories, or of 
opiate enemata. Trousseau, Dr. George Johnson, and others think that 
the diarrhoea should not be restrained, regarding it as a curative effort 
on the part of nature; that view, however, is not generally accepted, 
and is, we think, erroneous and dangerous. When haemorrhage from 
the bowels takes place measures should be adopted to arrest it. Dr. 
Murchison has great faith in the use, under such circumstances, of 
turpentine, tannic acid, ergot of rye, or other forms of astringents. 
Haemorrhage occurring, however, during the first ten or twelve days 
is of little importance, and does not usually call for treatment. For 
the prevention of perforation, the avoidance of purgatives, the arrest of 
diarrhoea, and the maintenance of a quiescent condition of the bowels, 
^ are of extreme importance ; it is further necessary to prevent the patient 
from using muscular exertion, and from taking articles of food likely 
to upset the stomach. If indications of perforation of the bowel mani- 
fest themselves, our only hope lies in keeping the patient under the 
influence of opium or morphia — the dose and frequency of its admin- 
istration being determined partly by the patient's age, but chiefly by 
its effects. Tympanites may be benefited by the use of stimulating 
enemata or hot fomentations to the belly. Sickness may be relieved 
by the use of lime-water and milk, bismuth or ice, or by counter-irri- 
tation. Pulmonary complications should be guarded against by the 
maintenance of an equable temperature, and by the avoidance of 
draughts. When present they must be treated on general principles. 
The great tendency there is to the formation of bed-sores makes it 
very important to keep the patient scrupulously clean and dry, to take 
measures to obviate or relieve pressure, and, if precursory redness makes 
its appearance, to anoint the part with some stimulating and protec- 



EPIDEMIC CHOLERA. 



223 



tive application. The diet should consist of fluid and easily digestible 
food given frequently (every hour or two), and in small quantities. 
The best aliments are milk, gruel, barley-water, rice-water, and such 
like; but arrowroot, sago, chicken-broth, beef tea, and eggs are valua- 
ble. Stimulants are necessary where there is tendency to collapse, 
where typhoid symptoms are present, or where there is great debility. 
In many cases, however, though their administration in moderate 
quantities can do no harm, they are by no means absolutely needed at 
any period of the disease. 

Much care is necessary during convalescence. The great debility 
which endures so long demands the use of tonics, and an abundance 
of nutritious food. But the liability to perforation of the bowel 
(which may not cease until the end of two or three months) makes it 
specially important that the food should be easily digestible, and not 
of such a character as to derange the action of the bowels. Moreover, 
the liability to the supervention of pulmonary inflammation and of 
tuberculosis renders exposure and fatigue particularly liable to be 
injurious. Change of air is often extremely beneficial. 



EPIDEMIC CHOLERA. (Asiatic or Malignant Cholera.) 

Definition. — An epidemic disease, of which the attacks are very 
severe and rapidly fatal, characterized by copious discharge of watery 
fluid from the alimentary canal, suppression of the urine and other 
secretions, shrinking of the tissues, cramps, and extreme prostration. 

Causation and History. — Epidemic cholera is a disease which has 
been known in India for centuries, and probably from time immemorial. 
It is rarely entirely absent there, but at irregular intervals breaks out 
into widespread epidemics. The first Indian outbreak which specially 
interests us is that which, originating in the Delta of the Ganges in 
the year 1817, soon ravaged the greater part of Hindostan, and during 
the next ten or twelve years spread over nearly the whole of Asia, 
including the Burmese empire, China, Tartary, and Persia. In 1829 
it commenced its progress through Tartary and Persia into Europe, 
and in that year it reached Orenburg. It then became temporarily 
arrested; but subsequently took a fresh start, and still travelling 

I slowly westwards it appeared in the spring of 1831 in European Rus- 
sia and Poland; and in October invaded Hamburg, Berlin, and 

j Vienna. In the same month cases were imported into Sunderland, 

I and the disease remained endemic in this country for fourteen months. 

j Having thus reached the northwestern angle of Europe, the epidemic 
divided into two branches, one of which crossed the Atlantic and ap- 

| peared in Quebec in 1832, thence diffusing itself over the North 
American continent ; the other turned southwards, attacking succes- 
sively France, Spain, Italy, and the Northern Coast of Africa. The 
disease did not finally leave Europe until the year 1837. Since the 
epidemic of 1817, numerous other epidemics have occurred in India; 

It. ' i: 



224 



SPECIFIC FEBRILE DISEASES. 



and several times the disease has spread slowly thence to Europe and |j 
to this country — not, however, always taking the same route as on the 
first occasion. 

The first British epidemic was that, above referred to, of 1831-32, t 
the second that of 1848-49, the third of 1853-54, and the last that of 
1865-66. On each of these occasions the disease was distinctly im- 
ported into this country by passengers or sailors coming direct from 
infected places, and its general prevalence was always preceded by 
local outbreaks in the seaport towns to which such infected visitors > 
were admitted. The general history of these epidemics, so far at least I 
as relates to England, has been that isolated outbreaks occurred in the 
autumn of the first year, that the disease died out with the approach |i 
of winter, and reappeared with extreme virulence in the later spring, j) 
summer, or early autumn of the second year, lasting for some two or i 
three months, and then disappearing altogether. It might appear from i 
this that its prevalence was largely determined by season ; and, indeed, 
there is strong evidence to show that high temperature is on the whole fe 
favorable, and cold inimical to its spread. Yet, on the other hand, 1 
the disease has prevailed with the greatest severity in Moscow, Sweden, 
and other northern countries in the depth of winter. 

To what cause or causes is epidemic cholera due ? This is a question 
which has been the subject of innumerable discussions and investiga- ; 
tions during the last fifty years. The horror which the disease occa- 
sions, the slowness yet certainty of its onward march, its sudden and 
capricious outbreaks, and its equally capricious subsidence and then 
total disappearance, all conspire to invest it with an atmosphere of 
mystery. Like influenza, it is the very type of an epidemic disease ; 
and like epidemic diseases generally, therefore, has been largely held » 
to be due to some atmospheric or telluric condition, some peculiar "epi- 
demic constitution," which, diffusing itself from country to country, i 
gives to the prevailing maladies a choleraic character, and produces i 
where local circumstances are favorable an outbreak of the fully-de- 
veloped disease. There is much to be said, no doubt, in favor of this o 
view; but the questions then naturally arise — "on what does this epi- 
demic constitution depend?" and "what are the local conditions which 
favor its operation ?" These questions are not easy to answer. We may f 
point out, however, as bearing upon them, that although heat and cli- 
mate have (as has been stated) some influence over the propagation of 
the disease, there is no good reason to believe that moisture or drought, 
excess or deficiency of electricity or of ozone affect it either one way or 
the other; that, according to Pettenkofer, localized outbreaks of cholera 
are determined in great measure by peculiarities of soil — the ground U 
must be porous and a superficial layer of it unoccupied by " ground | 
water," and penetrable by air; that, as shown by numerous observa- 
tions, the disease is much more apt to prevail in low-lying districts than 
in those which are much elevated above the sea ; that, according to Mr. J 
Glaisher, a peculiar blue mist prevailed throughout this country dur- 1 
ing the epidemic prevalence of cholera, both in 1866 and in previous 
cholera years; and that vegetable fungi which have been detected by 
numerous observers in cholera stools have often been assumed to 



EPIDEMIC CHOLERA. 



225 



pervade the atmosphere and to be the specific cause of cholera. These 
latter have been specially investigated by Hallier, who recognizes in 
the stools and vomit a form of urocystis consisting partly of mem- 
branous spore-cases containing yellowish or brownish spores, and partly 
of cells of extreme minuteness which he believes to have been de- 
veloped within these spores. These fungi he has cultivated in various 
ways; and he believes that he has obtained from them forms of peni- 
cillium, mucorj and the like, all of which he regards as polymorphous 
conditions of one and the same fungus. It must be added, however, 
that this particular form of fungus has certainly not been recognized 
by most others who have been engaged in similar investigations. Lastly, 
in relation to the subject now under discussion, it may be. pointed out 
that cholera has often been attributed to the accidental or designed 
poisoning of springs, and to the use of diseased cereals, especially rice, 
and even of unripe fruit. 

Again, in favor of the dependence of cholera on some miasm or epi- 
demic constitution was the striking fact that, although cholera affected 
large numbers of persons within a short time, there was little evidence 
of its communicability by direct contagion. It was noticed and has 
been constantly observed that the nurses and medical attendants rarely, 
if ever, take the disease from the patients under their charge, and that 
the introduction of cholera patients into a general hospital is by no 
means necessarily followed by the spread of the disease to other pa- 
tients. 

Nevertheless, it has always happened that the spread of cholera epi- 
demics has followed lines of traffic, showing that human intercourse, 
not winds,- has been instrumental in their propagation. In every in- 
vasion of this country, the disease has been first distinctly imported 
into our seaport towns by the arrival thither of infected persons from 
infected localities; and thence the disease has been carried by like 
means to other localities in direct relation with them by railways or 
other lines of traffic, and has thus gradually becouie distributed through- 
out the country, not generally but by local outbreaks. The fact that 
cholera though obviously not directly contagious, or at all events not 
directly contagious in a high degree, yet had some mysterious relation 
with the movements of mankind, and never broke out in any isolated 
country or town without having been distinctly imported into it by 
human agency, w T as manifestly opposed to most of the theories of its 
causation which have been previously referred to and had generally 
prevailed. Dr. Snow, now some years since, first shrewdly suspected 
that the cholera contagium was contained in the cholera-evacuations, 
and that the disease was propagated by the entrance of minute quanti- 
ties of such evacuations, through the medium for the most part of w T ater 
contaminated therewith, into the alimentary canal. And numerous 
facts and investigations, some of the most remarkable being conducted 
by himself, have entirely confirmed the correctness of his prevision. 
The matter is so important that we may quote a few of the best es- 
tablished and most striking cases. 

The cholera epidemic of 1849 was specially severe in the south of 
London, which was supplied with drinking-water mainly from surface 

15 



226 



SPECIFIC FEBRILE DISEASES. 



wells and by two water companies, the South war k and Vauxhall and 
the Lambeth, which derived their water from the Thames — the one in 
the neighborhood of Hungerford Bridge, the other in that of Battersea 
Fields — and supplied it in a very imperfectly filtered condition. At 
that time all the sewers of Loudon discharged themselves into the 
Thames, the water of which was consequently very foul. The cholera 
epidemic of 1854 was also very severe in South London. But between 
1849 and 1854 the Lambeth Company had removed its intake from 
Hungerford Bridge to Thames Ditton, and consequently furnished an 
infinitely purer water than it had done in 1849; the other company 
continued to draw its water-supply from the neighborhood of Batter- 
sea Fields. At this time the two companies were acting in rivalry, so 
that in many streets their mains ran side by side, and houses, under the 
same sanitary conditions in other respects, received a different water- 
supply. A careful investigation of the distribution of cholera in South 
London in this year, conducted mainly by Dr. Snow but with the assist- 
ance of the Registrar-General, gave the following results : 

Population in Cholera Deaths Cholera Deaths 
1851. in 14 weeks. per 10,000. 

Houses supplied by South wark Company, . 266,516 4093 153 

" " " Lambeth Company, . 173,748 461 26 

The facts were even more remarkable when examined in detail, in- 
asmuch as in streets and localities which both companies supplied, the 
disease singled out the houses furnished by the South wark Company. 

During the same epidemic a remarkable outbreak occurred within a 
limited area, in the neighborhood of Golden Square, London, the facts 
of which were also examined into by Dr. Snow. There had been a few 
cases in the neighborhood during the month of August, including, alto- 
gether, up to the 30th, nine deaths. On the 30th, at least eight cases, j[ 
which ultimately proved fatal, occurred ; during the 31st (and chiefly 
during the night), fifty -six ; during Sept. 1st, one hundred and forty- 
three; during the 2d, one hundred and sixteen; during the 3d, fifty- 
four ; and then daily, until the 9th, forty-six, thirty-six, twenty, twenty- 
eight, twelve, eleven, after which the disease rapidly disappeared. 
No less than six hundred and sixteen persons were ascertained to have P 
been fatally attacked with cholera within this area between Aug. 19th 
and Sept. 30th, of whom at least four hundred and fifteen contracted the L 
disease between the night of the 31st and that of Oct. 4th. It would i 
take much more space than is at our disposal to enter fully into details, 
suffice it to say that Dr. Snow's investigations proved, beyond the 
shadow of a doubt, that this sudden and evanescent outbreak was dis- 
tinctly due to the use of the sewage-contaminated water of the Broad 
Street pump occupying the centre of the affected area, the water of 
which was held in great repute, and was largely drunk by those who 
lived in its neighborhood. 

Again, the epidemic of 18,66 was remarkable in the fact that it was | 
limited almost exclusively to a circumscribed area in the east of Lon- 
don, including more especially Bethnal Green, Whitechapel, St. [ 
George's, Stepney, Mile End, and Poplar, together with the suburban \, 



EPIDEMIC CHOLERA. 



227 



districts of Stratford and West Ham. The inquiries of Mr. Radcliffe, 
conducted under the direction of the Medical Officer of the Privy 
Council, demonstrated with almost mathematical precision that the 
localization of the epidemic was due almost entirely to the distribu- 
tion to these districts of impure and unfiltered water by the East Lon- 
don Water Company. 

It must be assumed, therefore, as a fact, that the choleraic poison is, 
at all events in a large number of cases, conveyed through the medium 
of foul drinking-water, and necessarily, therefore, through the medium 
of all articles of food or drink to which such water may be added. 
But it still remains to ask, " How does the poison reach the water, 
whence does it come, and what is it ?" It would naturally be sup- 
posed that the choleraic poison is contained within the cholera stools — 
and indeed there is plenty of evidence to show that the drinking of 
water directly contaminated with small quantities of rice-water evacua- 
tions has induced an attack of cholera — and, as regards the local out- 
breaks above adverted to, it is certain that the incriminated waters 
were contaminated with sewage, and that there was at least the proba- 
bility that that sewage contained the evacuations of cholera patients. 
But, on the other hand, there is good reason to believe that the freshly- 
passed stools are not specifically noxious. Much, however, of what 
seems mysterious in reference to these matters seems to be explained 
by the important experimental inquiries first conducted by Professor 
Thiersch, and since repeated by Dr. Sanderson in this country. The 
experiments which yielded the most striking results were those per- 
formed on mice. It was ascertained by these gentlemen that, when 
mice were fed, under certain conditions, with cholera evacuations, they 
became attacked with symptoms which rapidly proved fatal, and that 
both symptoms and post-mortem appearances had a very close resem- 
blance to those of human cholera. The chief points of resemblance 
consisted in the rapidity and intensity of the disease ; in a remarkable 
lowering of the temperature (sometimes as much as 20 degrees) ; in the 
accumulation in the intestines of thin fluid containing bacteria, other 
lowly organisms, and abundance of shed epithelia ; and in the dis- 
charge of loose stools from the anus. The method adopted by Dr. 
Sanderson to infect the mice was to soak pieces of filter-paper in fresh 
cholera evacuations, or in the contents of the bowels of patients dead 
of cholera, to dry them, to ascertain by weighing the quantity of solid 
matter thus added to them, to cut them into pieces an inch square, to 
soak them in bacon fat, and then to administer them to the mice. The 
mice under these circumstances ate them greedily. The consequences 
were, that, of mice fed with paper prepared from evacuations which 
had not been allowed to stand more than twenty-four hours, 1 1 per 
cent, were affected ; of those fed with paper prepared on the second 
day, 36 per cent.; of those fed with paper prepared on the third day, 
100 per cent. ; of those fed with paper prepared on the fourth day, 71 
per cent. ; of those fed with paper prepared on the fifth day, 40 per 
cent. Paper prepared subsequently had no effect. These experiments 
show that the cholera evacuations have little or no intensity of action 
when perfectly fresh ; that their virulence increases up to the third 



228 



SPECIFIC FEBRILE DISEASES. 



day, diminishing again during the fourth and fifth days; and that they 
lose all specific properties after that date. It should be added that the 
evacuations from the diseased mice produced the same effects on healthy 
mice as did true cholera evacuations, and further, that all experiments 
made by Dr. Sanderson in the month of November failed absolutely, 
probably, as he suggests,, on account of the low temperature then pre- 
vailing. 

The application of the above results in explanation of the phenomena 
connected with the causation of cholera is obvious. And it is fair to 
conclude from them, and from the other facts which have been ad- 
duced, that the specific poison of cholera is furnished by the discharges 
taking place from the mucous surface of the alimentary canal ; that 
these are not operative when completely fresh, but that they acquire 
virulent infectious properties in the course of the following two, three, 
four, or five clays, and subsequently lose them ; that the poison of the 
disease is taken up by, or acts upon, the mucous membrane of the 
bowels, which it reaches through the mouth ; and that, while un- 
doubtedly it may be conveyed to the mouth under uncleanly circum- 
stances from saturated bed-clothes and direct contamination of culinary 
utensils, food or fingers, larger outbreaks of the disease are due to the 
infection of drinking-water (well, pond, or river) with cholera poison 
derived from cesspools, sewers, or other such sources. 

There can be little doubt, from the facts of its active powers of mul- 
tiplication, that the cholera poison is an organized contagium ; that 
one phase of its normal active existence is passed external to the body ; 
but that that existence is of short duration, and probably readily de- 
stroyed or rendered innocuous by cold and other agencies. 

Symptoms and Progress. — The duration of the incubative stage of 
cholera is not certainly known. It probably varies generally between 
a few hours and three days. The symptoms of invasion present con- 
siderable variety. In some cases a general indefinable feeling of ma- 
laise, associated with noises in the ears and lowness of spirits, precedes 
all other symptoms. In a very large proportion of cases (either in suc- 
cession to the last or arising independently) there is more or less loose- 
ness of the bowels (premonitory diarrhoea) coming on a few hours, a 
day, or even tw T o or three days before the nature of the disease is dis- 
tinctly revealed. Premonitory diarrhoea of even longer duration has 
not unfrequently been observed ; but in most such cases there is reason 
to suspect that the relation of the diarrhoea to the subsequent attack of 
cholera was accidental only. Lastly, in some instances the invasion of 
cholera is quite sudden. Omitting the premonitory symptoms which 
have just been considered, the first indication of an ordinary attack of 
cholera usually consists in the sudden and uncontrollable evacuation 
(with or without pain) of an abundant loose stool, composed mainly 
of the proper contents of the alimentary canal in a fluid or semifluid 
state. To this succeeds a continuous or intermittent flux of fluid, at 
first bile-stained, but subsequently thin, colorless, or opaline, without 
fecal look or smell, and containing in suspension whitish flocculi. The 
amount of fluid thus discharged is sometimes enormous ; four or five 
pints, or enough to fill a chamber-pot, may be passed in the course of 



EPIDEMIC CHOLERA. 



229 



an hour or two. Sickness for the most part attends the diarrhoea, but 
generally comes on a little later. The matters first vomited are the 
ordinary contents of the stomach and of the duodenum ; but after these 
1 have been got rid of, the vomited fluid exactly resembles that which is 
flowing simultaneously from the anus, and may be almost as abundant. 
Shortly after the vomiting and diarrhoea have become established, 
| severe cramps, attended with agonizing pain, come on in the thighs 

, : ! and calves, in the arms, hands, feet, and parietes of the abdomen. And 
very speedily the patient falls into a state of extreme collapse — the so- 
called " Algide" stage ; his tissues shrink ; his fingers and toes become 

| shrivelled and corrugated, and his eyes sink into their sockets ; his 
surface becomes more or less notably livid, and sometimes as blue as 
that of a cyanotic patient — this change being especially noticeable in 
the hands and feet, in the cheeks, lips, and around the eyes, and in the 

I tongue, which looks like a piece of lead ; his respirations grow rapid 
and shallow, and his voice hoarse or squeaking, feeble, and reduced 

i almost to a whisper; his pulse becomes rapid and thready, and soon 
scarcely, if at all, perceptible at the wrist or even in the brachial artery. 
At the same time his temperature falls; his surface becomes cold and 
clammy, and sometimes covered with cold sweats ; his tongue also and 
breath become manifestly cool. The temperature in the mouth and in 
the axilla falls rapidly to 95°, 94°, or even 92° ; and much lower tem- 

j peratures than these have been recorded. But while the general tem- 

i perature, and especially the surface-temperature, thus fall, that in the 
rectum and adjoining parts is considerably higher than natural, and 
may be 101°, 102°, or even above that. The urinary and biliary 
secretions are totally suppressed. The patient is wakeful and restless, 
throwing his arms about, complaining much, probably, of intense thirst 
and of burning at the chest, but withal singularly apathetic. When 
the condition of collapse — the cold stage — is fully established, the 
vomiting and diarrhoea either cease completely or greatly diminish, 
and the patient lies ghastly and livid like a corpse, with eyes open and 
pupils dilated, torpid, yet still retaining his senses. During this period 
the muscular power is greatly enfeebled ; yet occasionally the appar- 
ently moribund patient will rise up in his bed, and even get up and 
walk across the room. The duration of this stage of the disease varies 
very much; sometimes the patient dies in two or three hours from its 
commencement; but more frequently that event is delayed beyond 
eight hours, very often occurs between the tenth and fourteenth, and 
is rarely prolonged beyond the twenty-fourth. 

The symptoms which have been above described are not all present 
in every case of cholera. The muscular cramps are sometimes alto- 
gether absent; while, in other cases, and these perhaps cases of no 
great severity, they are constant and agonizing. Again, vomiting and 
diarrhoea are not invariably present; and, indeed, their absence is 
almost characteristic of some of the most formidable attacks of the dis- 
ease — those, namely, in which the patient is struck suddenly with 
symptoms of extreme collapse, and dies in the course of an hour or 
two, or less. 

In those patients wdio survive the stage of collapse a gradual change 



230 



SPECIFIC FEBRILE DISEASES. 



in the symptoms manifests itself. The stage of reaction sets in. This 
stage is said to be often absent in the cholera of hot climates. In our 
own country, however, it is invariably present ; but its duration, and 
the severity of its symptoms, depend very largely on the intensity of 
the cold stage which preceded it. It generally comes on between the 
twelfth and fourteenth and the thirtieth hour after invasion. Its first 
indications are slight and vague. A general improvement is visible in 
the patient ; he becomes less restless, his breathing slower and more 
natural, his pulse just perceptible at the wrist, the lividity of surface 
slowly disappears, the shrunken tissues expand, the temperature rises, 
perspiration breaks out, and not improbably he falls into a comfortable 
sleep ; urine begins to be secreted, and the motions are again stained 
with bile. The temperature, however, generally rises somewhat above 
the normal, and more or less obvious febrile disturbance takes place. 
In some cases the reactionary symptoms are mild and end in convales- 
cence at the end of twelve or twenty-four hours ; but more commonly, 
especially when the cold stage has been severe and of long duration, 
these symptoms become aggravated, and may be prolonged (unless cut 
short by death) to between four and twelve days, sometimes yet longer. 
The general symptoms have then some resemblance to those of enteric 
fever ; the face becomes flushed, the eyes injected, the skin hot and 
studded sometimes with roseolous patches, the pulse increased in power 
and volume and accelerated, the respiration a little more rapid than 
natural, the tongue furred, sometimes dry and brown, and the temper- 
ature one, two, or three degrees above the normal ; the patient may also 
present more or less delirium, or lie in a torpid or comatose condition. 
The motions, according to Dr. Sutton's observations, consist often on 
the first establishment of reaction of a thin, yellowish fluid, which 
looks like and may be mistaken for urine, and often then contain a 
kind of gelatinous substance ; but soon they become green from con- 
tained bile, next peasoup-like, and then, consolidating, gradually ac- 
quire their normal character. Occasionally, early in the stage of reac- 
tion, the stools contain blood, the quantity varying from a mere trace, 
just sufficient to impart to them a pale pink tinge, up to a flux sufficient 
to undergo very complete coagulation. The stools of the reactive 
period are often very fetid. The re-establishment of the urinary secre- 
tion is a most important element in the progress of the disease. In 
mild cases it sometimes takes place in twelve hours or less; it is more 
commonly delayed to between twenty-four hours and three days, and 
may be delayed until the fourth, fifth, or sixth day. The urine first 
passed is in extremely small quantity, and often, during the first twen- 
ty-four hours, remains far below the quantity usual in health. Subse- 
quently the patient may pass four, five, or six pints daily. At first it 
is a little turbid, contains traces of albumen, casts of the urinary tubules, 
and epithelial cells from other parts of the urinary passages, but pre- 
sents a very small amount of urea and of uric acid, as also of chlorides, 
phosphates, and sulphates. The color varies. Subsequently, when 
marked fever comes on, and the urine at the same time increases in 
quantity, the amount of urea in it increases and exceeds by a greater 



EPIDEMIC CHOLERA. 



231 



or less degree that which is present in healthy urine. Urocyanogen 
may sometimes be found in it. 

The causes of death in the stage of reaction, and the phenomena 
which precede it, present considerable variety. Sometimes cough and 
difficulty of breathing, with pulmonary engorgement or consolidation, 
carry the patient off. At other times he seems to sink under the con- 
I tinuance of intestinal flux, especially when haemorrhage accompanies it ; 
or symptoms much like those of enteritis supervene. In some cases 
convulsions, or coma, or other cerebral symptoms precede and appar- 
ently cause death ; there is good reason to believe that not unfre- 
quently the cerebral complication is immediately due to ursemic poison- 
ing. Lastly, the patient sometimes sinks from mere asthenia arising 
directly out of his primary symptoms, or supervening on his typhoid 
condition. 

In the description of cholera above given we have adverted to some 
of the varieties which its attacks present. Especially we have pointed 
out, or have incidentally mentioned, that in some cases the patient is 
struck down with the disease, and dies in extreme collapse at the end 
of perhaps two or three hours, without ever having passed an evacua- 
tion ; that in a still larger number of cases the characteristic vomiting; 
and diarrhoea are present, the stage of collapse gradually supervenes, 
and the patient dies in this stage at the end of from (say) ten to twenty- 
four hours; that in many cases again, even of considerable severity, 
the patient emerges from the condition of collapse into one of febrile 
reaction, during which he may perish in one of the modes above enu- 
merated, or from which he may glide into convalescence; and, lastly, 
that in some cases, notwithstanding the presence of rice-water stools 
and other quite characteristic signs of the disease, the patient scarcely 
becomes collapsed at all, and very speedily regains health and strength. 
This enumeration leads up to the important questions as to how far 
cholera may be so mild as to simulate in its attacks mere summer or 
autumnal diarrhoea, and how far also it is possible that this latter which 
(in this country, at all events) concurs with the epidemic prevalence of 
cholera is influenced by the choleraic poison. As to the former ques- 
tion, there can be no doubt, we think, that, just as enteric fever, 
typhus, scarlatina, and other like affections, are sometimes so mild and 
slightly developed as to be (except it may be from associated circum- 
stances) incapable of identification, so cholera may be so mild and so 
shorn of everything characteristic as to be unrecognizable as cholera ; 
and hence that cases of undoubted cholera may simulate, and be taken 
for, cases of ordinary unspecific diarrhoea. As to the latter question, 
it may be remarked that those who regard cholera as being the out- 
come of some " epidemic constitution " of the atmosphere, or of some 
all-pervading miasm, might reasonably believe that all morbid con- 
ditions tend during the prevalence of cholera to take on a choleraic 
character. Those, however, who believe the choleraic poison to be a 
form of contagium, and accept those views of its operation which we 
have endeavored to uphold, w T ould necessarily discredit its general 
influence, excepting in the face of overwhelming evidence in favor of 
the existence of such influence. But no such evidence, we think, exists. 



232 



SPECIFIC FEBRILE DISEASES. 



It seems to us, indeed, a fundamental and mischievous error to regard 
the diarrhoea which precedes and. accompanies epidemics of cholera as 
having any other than a fortuitous connection with them. 

The mortality of cholera is very great; it varies in different coun- 
tries and in different epidemics, but in round numbers may be said to 
be on the average about 50 per cent. It is said to be less fatal towards 
the close of an epidemic than at its commencement ; and further, to be 
more fatal to the very young and very old than to those whose age lies 
between these extremes. 

Any affection attended with sudden and extreme collapse, especially 
if there be at the same time gastro-intestinal disturbance, may be mis- 
taken for cholera ; among those most liable to be thus confounded are 
some cases of arsenical poisoning, and of poisoning by croton oil ; 
severe summer cholera ; perforation of the stomach or bowel ; extensive 
enteritis; and the onset or cold stage of severe forms of remittent 
fever. 

Morbid Anatomy and Pathology. — The post-mortem appearances 
found after death from cholera differ greatly according as death takes 
place in the stage of collapse or in that of reaction. In the former 
case, the body retains the shrivelled character and more or less of the 
lividity which it presented during life, and the dependent parts aje 
often more or less deeply congested. The muscles not unfrequently 
contract for some little time after death, causing movements of the 
limbs ; and for the most part rigor mortis is well-marked and pro- 
longed. The tissues of the body are generally preternatural ly dry, 
the muscles firm and dark-colored, the systemic veins loaded with 
blood, which is manifestly thicker and perhaps darker than normal. 
The serous membranes are for the most part free from fluid effusion, 
are sticky to the feel, and not unfrequently present subserous extrava- 
sations of blood. The right cavities of the heart are always more or 
less distended with blood, which is dark-colored and imperfectly coagu- 
lated. The left ventricle is sometimes firmly contracted, or may con- 
tain a small quantity of coagulated or uncoagulated blood. The left 
auricle also contains a comparatively small quantity. The lungs are 
usually much diminished in weight, pale, anaemic, and dryish on sec- 
tion. Sometimes, however, they are congested and ©edematous below, 
and occasionally more or less congested and ©edematous throughout. 
The pulmonary arteries are usually gorged with blood, the veins nearly 
or quite empty. The liver presents no decided departure from health; 
the gall-bladder is full of bile. The spleen is generally reduced in 
size. The outer surface of the bowels is often injected or of a diffused 
rosy tint. Their mucous surface is sometimes of a nearly uniformly 
pink tinge, increasing in intensity towards the caecum; or it may pre- 
sent irregular patches of congestion, with submucous extravasations ; 
or it may be quite pale. It often presents a corrugated and sodden 
appearance; and the solitary glands and those of Peyer are for the 
most part enlarged. The contents are an opaline or gruel-like fluid, 
which is either white or rendered pink by admixture with effused 
blood. The mucous lining of the stomach is often more or less con- 
gested and mammillated, and its contents generally resemble those of 



EPIDEMIC CHOLERA. 



233 



the bowels. The kidneys are congested on the venous side, so that the 
medullary portions are injected, as likewise are the superficial veins, 
while the cortical substance, on the other hand, is more or less pale. 
The urinary bladder is firmly contracted and empty or containing a 
little pus-like fluid. The brain presents num erous puncta omenta. 

If death occurs during reaction the tissues are more moist; blood is 
found perhaps in equal degree on both sides of the heart, and not un- 
frequently thick fibrinous coagula are prolonged thence into the aorta. 
The lungs become congested and cedematous. The contents of the in- 
testines assume the character of pea-soup. Besides which changes 
pneumonia is sometimes met with, sometimes distinct inflammation of 
the intestinal mucous membrane. 

Other pathological facts of great interest have been ascertained with 
respect to this disease. The blood, as has been stated, is inspissated, 
though not by any means so much so as is commonly believed. The 
proportion of albumen and salts to its other solid constituents is di- 
minished; the white corpuscles are often increased relatively to the 
red; and the blood is (according to Dr. Thudichum) more adherent to 
the bloodvessels than natural. The rice-water fluid, as found in the 
intestines, is alkaline, in a rapid state of decomposition, and evolves 
gases (chiefly nitrogen and carbonic acid); it contains, besides bacteria, 
shed epithelium in abundance, mucin, albumen, and also butyric 
acid, acetic acid, ammonia, leucin, and inorganic salts. It does not, 
however, contain urea. There is no doubt that post-mortem the mu- 
cous surface of the bowels loses its epithelial covering, which is thrown 
off in flakes and suspended in the intestinal contents. It is doubtful, 
however, whether this is merely a post-mortem change or a lesion occur- 
ring during life. It is interesting to note that there is a similar pen- 
dency to shed the epithelial layer in almost every part in which it ex- 
ists, especially in the bladder and urinary passages, in the bronchial 
tubes, and in the ducts of the liver and of the salivary glands. Dr. 
Thudichum's observations show that during the period of collapse the 
blood and the tissues contain very little urea; but that the quantity in- 
creases during the period of reaction, and soon, if urine be not secreted, 
becomes excessive. 

It remains briefly to discuss the relations between the post-mortem 
appearances and the vital phenomena of the disease. It is obvious 
that we here have an affection which is characterized primarily and 
mainly by a sudden and profound impression on the mucous surface 
of the alimentary canal ; in dependence on which active destructive 
changes take place (as evidenced by the raised temperature of the 
parts) and large quantities of imperfectly filtered blood, with tendency 
to rapid decomposition, are poured forth with sudden impetuosity. 
The rapid and profuse discharge of fluid tends to cause inspissation of 
the circulating blood, and consequently indirectly, but very thoroughly, 
to drain the tissues of their interstitial fluid, and to cause them to 
shrivel up. Anasarca, indeed, if present becomes thus temporarily 
cured. The absorption of extravascular fluid into the bloodvessels 
tends, of course, to maintain the fluidity of the blood ; but, notwith- 
standing this, the blood almost invariably becomes thicker than 



234 



SPECIFIC EEBKILE DISEASES. 



natural, and less easy of transmission through the minuter vessels. 
On these conditions follow contraction of all the smaller arteries, ex- 
cepting, probably, those connected with the bowels ; general failure of 
the circulation ; arrest of normal destructive changes, and therefore of 
formation of urea ; arrest of urinary, biliary, and salivary secretions ; 
and diminution of the normal action of the lungs, with cyanosis, 
lowering of temperature, and, generally, collapse. All the above 
phenomena flow directly or indirectly from the effects of the cholera 
poison. But how and where does the poison act? Some believe that 
it acts simply on the intestinal mucous membrane as a local irritant, 
just as croton oil or elaterium acts, and that all the symptoms which 
ensue are the result of violent irritation of the mucous membrane and 
of the discharge which takes place from it ; and there is no doubt that 
symptoms almost identical with those of cholera may be produced by 
the local action of irritants and irritant purgatives. But if it be cor- 
rect, as it certainly seems to be, that the foetuses of mothers dying of 
cholera themselves give clear indications of having been affected with 
the disease, it is clear that the poison must be diffused throughout the 
system in addition to being contained in the alimentary canal. And, 
indeed, it is most consonant with all we know to regard cholera as a 
systemic affection. But whether we are therefore to assume, with Dr. 
George Johnson, that the choleraic virus is contained in the blood ; 
that by its presence there it causes cramp of the voluntary muscles on 
the one hand, and of the capillary arteries of the lungs on the other, 
so as to prevent the passage of blood through them ; and that the gen- 
eral collapse, loss of temperature, and suppression of secretions are due 
to this mechanical obstruction ; and, lastly, that the discharge from the 
bowels is an effort of nature (which should be encouraged) to eliminate 
the poison from the blood, is quite another matter. We confess that, 
in our view, the intestinal flux is not eliminative, but connected, as is 
the eruption of small-pox, with the local growth and multiplication of 
the poison ; and that there is ample explanation in the processes which 
are going on in the bowels of nearly all the subsequent phenomena of 
the disease, including collapse. It is obvious, however, that the pres- 
ence of inspissated blood in the vessels, the drying up of the moisture 
of the tissues, the contraction of the smaller branches of the pulmonary 
artery (assuming it to take place) must all co-operate to maintain the 
patient in the condition of collapse. 

Treatment. — The value of precautionary and hygienic measures in 
preventing or limiting the outbreak of cholera has never been better 
shown than in the history of our own epidemics. Pure water, well 
filtered, and carefully guarded from fecal contamination ; thorough 
domestic cleanliness, and, when cholera is present, the immediate dis- 
infection by carbolic acid or Condy's fluid of all evacuations, and of 
all contaminated articles, are conditions of the utmost importance in 
preventing the spread of the disease. 

The medicinal treatment of cholera resolves itself into the treatment 
of the prodromal stage, that of the period of collapse, and that of the 
stage of reaction. It is generally believed that the treatment of the 
premonitory diarrhoea is a matter of vital importance to the patient ; 



EPIDEMIC CHOLERA. 



235 



and the assumption that the diarrhoea which so often prevails when 
cholera is epidemic is actually cholera, or simple diarrhoea modified by 
choleraic influence, has led to the general belief in the importance of 
treating at such times all diarrhceal cases with the object of preventing 
their development into the graver malady. But, unfortunately, while 
the majority of physicians laud astringents for this purpose, others 
prefer castor oil, and all refer to statistics in proof of the efficacy of 
their respective modes of treatment. We have asserted our own belief 
that if a case be one of simple diarrhoea, it will not run on to cholera 
under any form of treatment; and we may add that, if the case be one 
of commencing cholera, there is no more ground for believing that it 
can be cut short than for believing that typhoid fever or hooping- 
coudi can be cut short. We do not believe that either castor oil or 
astringents have any such influence. 

In the period of collapse all sorts of remedies have been adopted ; 
some have given calomel in large doses, some opium, some brandy, 
some castor oil ; but it seems clear that drugs administered by the 
mouth must in such cases prove quite inoperative. And this is cer- 
tainly the opinion of nearly all except the enthusiastic supporters of 
some special drug. During this period the patient should be kept in 
the horizontal position ; he should be allowed cold or ice-cold water to 
relieve his insatiable drought ; and his surface should be kept warm 
by the application of hot bottles or flannels, or by friction. The 
placing of the patient in a bath, two or three degrees above blood heat, 
is often very comforting and apparently of much service. The vapor 
bath may also be beneficial. It is in this stage that the injection of 
saline fluids into the veins has been so often tried, and occasionally 
with success. The immediate effect of the injection is often marvel- 
lous, the moribund patient regains his healthy appearance, his respira- 
tions and pulse and voice assume a normal character, and he sits up 
in his bed conversing cheerfully. But the improvement is generally 
of short duration ; he falls again into collapse, and probably dies. The 
solution employed should resemble as nearly as possible the serum of 
the blood, and should be injected slowly and cautiously, in quantities 
varying, according to its effects, between 10 ozs. and one or two pints. 
Schmidt recommends the following: chloride of sodium 60 parts, 
chloride of potassium 6, phosphate of soda 3, carbonate of sdda 20 ; of 
which mixture 140 grains are to be dissolved in 40 ozs. of distilled 
water, and filtered. The temperature of the fluid as it enters the veins 
should be a little over that of the blood. Cramp may be relieved by 
friction, or the inhalation of chloroform. 

Great care must be taken of the patient during the reactionary stage. 
He should be kept cool. Diarrhoea and vomiting must be restrained, 
the former by astringents, such as Dover's powder, compound kino 
powder, or the aromatic powder of chalk and opium ; the latter by lime- 
water, bismuth, and the like, or the use of ice or the application of 
counter-irritants. The food should be fluid, nutritious, and unstimu- 
lating: milk, broth, arrowroot, sago, barley-water, and eggs, are the 
most appropriate. It is questionable whether stimulants are beneficial. 
If given they should be given in small doses much diluted. It is of 



236 



SPECIFIC FEBRILE DISEASES. 



essential importance that the urinary secretion be restored ; but it is 
unwise to employ stimulant diuretics for the purpose. Saline effer- 
vescents may both relieve sickness and at the same time promote urine. 
Cupping glasses and counter-irritation to the lumbar region are believed 
to be sometimes serviceable. If dysenteric or enteritie symptoms come 
on opium must be freely used. 



HYDROPHOBIA. (Rabies.) 

Definition. — A disease special to dogs, wolves, foxes, and animals 
closely related to them, among which it spreads by direct contagion, 
and from which it is imparted (but by inoculation only), to other ani- 
mals and to human beings. Its most characteristic features in man are 
the spasms and terror which are induced by the attempt to swallow 
fluids, or even by the thought of swallowing, and its invariably and 
rapidly fatal issue. 

Causation and History. — There is no evidence to show that this dis- 
ease ever arises spontaneously among dogs any more than small-pox 
does among men ; and further, there is reason to believe that it spreads 
among them by inoculation only, or rather, perhaps, by the introduc- 
tion of the saliva of diseased animals into the tissues of those which are 
healthy, by whatever process that introduction is effected. The cause 
of the disease is evidently a specific virus which resides mainly in the 
viscid secretions which are furnished by the mucous membrane of the 
mouth and fauces and by the salivary glands. The prevalence of 
rabies, like that of other infectious diseases, varies very greatly at dif- 
ferent periods; sometimes it is scarcely observed for many years to- 
gether, at other times it prevails widely in an epidemic form. The 
circumstances on which these differences depend are not obvious; for 
climate, season, dearth of water and of food, and other such conditions 
do not seem to have any influence over it. It is important, however, 
to know that the virus never inoculates when it is applied to the sur- 
face of the sound skin; and that only a small proportion of those who 
are bitten by rabid dogs become hydrophobic. This proportion has 
been variously estimated at from 5 to 50 per cent. One main reason 
doubtless of the immunity which so many who are bitten enjoy, is the 
fact that they are wounded through their clothes, and that the fangs 
are thus cleansed from all moisture before they enter the skin. 

Symptoms and Progress. — After a man has been inoculated with the 
saliva of an animal suffering from rabies, the wound in most cases heals 
as readily and quickly as a wound not so inoculated would heal; at 
all events, there is nothing in its progress to indicate the existence of 
anything unusual. A period of latency follows, which is generally 
remarkable for its long duration. In most cases the first symptoms 
show themselves between the fourth and eighth week, but they have 
appeared in the course of a few days, and have been delayed for months 
and even years. They rarely, however, appear after four months. 



HYDROPHOBIA. 



237 



The outbreak of Irydrophobia is in some cases preceded for a day or 
two by heat, tingling or pain at the part on which the injury had been 
inflicted, the pain being sometimes intense and extending upwards in 
the course of the sensory nerves. There is occasionally also renewed 
inflammation and suppuration or ulceration. In many cases, on the 
other hand, no such phenomena present themselves. 

The period of invasion, which is sometimes termed the melancholia 
stage, is attended with a variety of symptoms, most of which have no 
particular significance, and which gradually merge into those of the 
fully developed disease. The patient complains of feverishness and 
shivering, with dryness of mouth and thirst, want of sleep, epigastric 
uneasiness, and indefinable anxiety. He is pale, anxious, but dis- 
traught in his aspect with restless eyes and dilated pupils, restless and 
fidgety in his movements, garrulous but speaking in short sentences 
and in a jerky, abrupt manner. He suffers also from increased fre- 
quency of the heart's action and loss of appetite, perhaps nausea and 
vomiting; and not improbably has even now some feeling of constric- 
tion about the fauces, with a disinclination to swallow fluids, quickened 
and sighing respiration, general hyperesthesia, and a tendency to pria- 
pism and seminal discharges. 

At the end of two or three days the next stage has become fully de- 
veloped. This is sometimes termed the stage of excitement, and in it 
the disease assumes all its typical features. The strange agitation of 
the patient has become more marked ; his eyes are bright, mobile, wild, 
and glance with suspicion or terror about him ; his hair is rough, his 
skin pale, his brow contracted, his aspect indeed closely resembles that 
of a patient with acute mania; he is still inclined to be talkative, fre- 
quently making odd but pertinent remarks ; he is probably quite sen- 
sible and capable of understanding and reasoning ; at the same time 
he is obviously under the domination of some indefinable but great 
horror ; and occasionally perhaps he has hallucinations, and is liable to 
outbreaks of violent maniacal excitement in which he may endeavor 
to injure himself or others. The thirst has increased, his mouth and 
fauces are congested and dry, and a quantity of tenacious saliva accu- 
mulates, which he is constantly hawking up and spitting about him 
with a noise which has often been taken for a bark. But, above all, the 
disinclination to swallow fluids has now become an almost perfect ina- 
bility to swallow them, and a dread of making the attempt. He will 
still perhaps resolutely try to drink, will take the glass of water in his 
hand, prepare himself with strange calm and deliberation to make one 
supreme effort, put the vessel hurriedly to his lips, make a sudden gulp, 
and then, with or without swallowing a little of it, eject the bulk of it 
spasmodically and violently from his mouth, and throw the glass away. 
A convulsive attack has been induced, marked by general tremors or 
shuddering, and violent spasmodic action of the muscles of deglutition 
and respiration, which lasts for a few seconds, and leaves the patient 
for a minute or two in a state of painful agitation. The fear of the 
recurrence of these terrible convulsions is constantly before him, and 
their actual recurrence is soon induced, not merely by the attempt to 
swallow, but even by the sight or sound or thought of fluid. The gen- 



238 



SPECIFIC FEBKILE DISEASES. 



eral hyperesthesia, which has already been adverted to, becomes more 
acute. The patient will often complain of the mere weight of the hand, 
or of his bedclothes ; and a draught of cold air upon the surface suf- 
fices to induce a convulsive attack. Bright objects, and loud or harsh 
or unaccustomed sounds are painful to him, excite a feeling of terror, 
and not unfrequently also provoke convulsions. The sexual excite- 
ment, of which the patient complains bitterly, may also continue. He 
passes urine frequently. 

As the disease progresses all the symptoms become more severe; the 
patient gets more feeble, his pulse quick, irregular, and small, his skin 
clammy, his voice hoarse, the tenacious mucus which is secreted by the 
mouth and fauces accumulates and becomes more difficult of expulsion ; 
the paroxysms of general convulsive action and of spasm of the respi- 
ratory muscles increase in severity and frequency; and at length he 
dies either of sudden asphyxia in one of these convulsive attacks, or of 
slow asphyxia induced by their rapid recurrence, or of exhaustion, 
aided possibly by a general paralytic condition. 

The most remarkable of the phenomena of the disease consist, 1st, in 
the hyperesthesia of the skin and of the organs of sense ; 2d, in the 
tendency which impressions on these organs, and which attempts to 
swallow, or thoughts of swallowing liquids have in producing clonic 
and tonic spasms of the respiratory muscles ; and, 3d, in the wakeful- 
ness, horror, and tendency to yield (while apparently still quite rational) 
to insane impulses. The disease is invariably fatal, and generally ter- 
minates between the second and fourth day. 

We may mention here that rabies in dogs presents to a great extent 
the same symptoms as hydrophobia in man. There are, however, one or 
two important points of distinction : thus, dogs are not afraid of water, 
and will indeed, on the contrary, bury their muzzles in water while at 
the height of the disease ; cutaneous hyperesthesia seems to be absent 
in them; and towards the close a paralytic condition supervenes, in- 
volving especially their hinder extremities and the lower jaw. 

Morbid Anatomy has not as yet thrown any light upon the phe- 
nomena of hydrophobia. The muscles retain their rigidity for some 
time after death, and there is more or less obvious congestion of the 
posterior surface of the corpse, of the fauces, pharynx, oesophagus, 
larynx, and trachea, of the lungs, and of the central nervous organs. 
In a case recorded by Mr. Cooper Forster, small extravasations of 
blood were found in the gray matter of the cervical and dorsal regions 
of the cord. There can be little doubt that the hydrophobic virus ex- 
erts its influence mainly on the sensory and emotional regions of the 
central nervous organs. Dr. Marochetti, in 1820, described the forma- 
tion of small vesicles beneath the tongue in persons bitten by mad 
dogs. These vesicles, which have also been described subsequently by 
one or two other physicians, are said only to occur during the second 
week after inoculation. 

Treatment. — Whenever a patient has been bitten by a rabid animal 
or one suspected of having rabies, the wounded part should be at once 
excised and the remaining raw surface freely treated with caustic pot- 
ash, nitric acid, the acid nitrate of mercury, the actual cautery, or some 



OL ANDERS — FARCY. 



239 



other equally efficient destructive agent. In such cases, too, it may be 
well to look carefully for sublingual vesicles and to cauterize them, for 
it is asserted (although it is highly improbable) that their cauterization 
and destruction prevent the supervention of hydrophobia. No remedy 
has been discovered competent to arrest the progress of the once estab- 
lished disease. Drugs producing narcotism and anaesthesia might seem 
to offer some chance of benefit, but none has been found of service, ex- 
cept perhaps in the relief of suffering. They (and indeed all drugs) 
should be administered by inhalation, or by the rectum, or by subcu- 
taneous injection. Tracheotomy has been suggested in the hope of 
averting death by asphyxia. Great care should be taken to prevent 
the patient from doing violence either to himself or those about him, 
and especially to prevent inoculation of wounds by the saliva which 
he disperses. 



GLANDERS. FARCY. (Equinia.) 

Definition. — A specific disease, special to the horse and animals of 
the same genus, but communicable to man, and characterized by a 
peculiar tubercular affection of the nasal and respiratory mucous mem- 
branes and a similar affection of the skin, lungs, lymphatic glands, and 
other parts of the body. 

Causation and History. — Whether the disease originates spontane- 
ously in the horse is a matter of dispute. It is certain, however, that 
it spreads readily among horses and from them to man by contagion, 
mainly by the virus contained in the secretions yielded by the nasal 
mucous membrane ; and, further, that it is similarly transmissible from 
man to man. 

Symptoms and Progress. — The period of incubation probably varies 
between one and about fifteen days. It is said to be occasionally much 
prolonged. Two varieties of equinia are met with which go by the 
respective names of glanders and farcy; the difference between them 
depending mainly on the seat of inoculation, and on the absence or 
presence of early affection of the nose and air-passages. These varieties 
run into one another even in the horse ; in man they are generally com- 
bined. The symptoms of invasion are those of intense febrile disturb- 
ance, heat of skin, rigors, acceleration of pulse, headache, febrile urine, 
pains in muscles and in joints, and often nausea and vomiting, and 
profuse perspirations. The specific phenomena of the disease soon 
follow. These consist in an affection of the nasal mucous membrane 
and of the mucous surfaces which are continuous with it, and an erup- 
tion on the skin. The mucous surface of the nostrils becomes con- 
gested and secretes a thin, acrid, watery discharge, which soon becomes 
thick, tenacious, and profuse, and finally probably assumes the charac- 
ters of sanious pus. The cutaneous eruption is thinly and irregularly 
scattered, and chiefly on the face, extremities, neck, and abdomen. It 
consists at first of red points ; but these soon increase in size, attaining 



240 



SPECIFIC FEBRILE DISEASES. 



the bulk ultimately perhaps of peas, and feeling hard and shotty be- 
tween the fingers, and not unlike syphilitic chancres. A vesicle or 
pustule soon makes its appearance on the summit of each spot, enlarges, 
bursts, exudes a more or less abundant purulent fluid, and leaves an 
irregular sloughy ulcer, surrounded by a livid margin. A little later, 
other phenomena manifest themselves ; the conjunctivas yield a purulent 
secretion, sores appear on various parts of the mucous surface of the 
oral cavity and pharynx, and bronchitic, pulmonic or pleuritic symp- 
toms are added ; erysipelatous redness and swelling of the eyelids, nose, 
cheeks, and forehead become developed ; and subcutaneous or deeper- 
seated tubercles and abscesses — the latter often of considerable size — 
appear in various parts, but mainly in the face and in the vicinity of 
joints. Whilst these symptoms are in progress the patient becomes 
weak and prostrate, his pulse quick and feeble, his muscles tremulous, 
his tongue dry and brown, and delirium comes on ; in a word, typhoid 
symptoms rapidly develop themselves, on which coma supervenes, and 
death soon follows. The breath during this period is generally very 
fetid, the perspiration abundant, there is often diarrhoea, and gangrene 
sometimes attacks the nose, eyelids, and other parts. The course of 
the disease is generally acute, the temperature may. rise to 104° or 
even to 106°, and death supervenes sometimes during the first few days, 
but more commonly between the seventh and fifteenth or sixteenth. 
Occasionally in man (but much more commonly in the horse) the dis- 
ease is chronic. The invasion is then more gradual, the various phenom- 
ena follow one another at longer intervals, and the eruption is often 
absent, but the subcutaneous abscesses which form become larger, the 
resulting ulcers are often attended with sloughing, and the affection 
of the nostrils extends and leads even to the exposure and destruction 
of the bones. The patient passes into a hectic condition, and may 
linger for weeks, months, or years. The blood is said by Colin to be 
greatly surcharged with white-corpuscles. 

Farcy is generally dependent on the inoculation of a wound on some 
part of the trunk or limbs. The inoculated part becomes inflamed and 
painful, and the absorbent vessels and glands in relation with it soon 
similarly affected. Then supervene more or less of the febrile dis- 
turbance that characterizes glanders, and the formation of subcutaneous 
lumps (farcy-buds) and abscesses; frequently, too, the absorbent glands 
become generally inflamed, and suppurate. The cutaneous rash is not 
so frequently present in farcy as in glanders, and the nasal inflamma- 
tion is often absent. It must be added, however, that all the special 
symptoms of glanders occasionally supervene. This variety of equinia 
may occur either in the acute or chronic form. The latter is sometimes 
exceedingly ill-marked and difficult of diagnosis. 

Equinia is generally a fatal disease. The chronic forms are most 
likely to be followed by recovery, and farcy more so than glanders. 
In its early stage, and in the absence of rash or nasal implication, 
equinia may be readily mistaken for acute rheumatism or pyaemia. 

Morbid Anatomy. — The anatomical phenomena of equinia consist 
mainly in the formation of tubercles, presenting to a considerable ex- 
tent the structural features of true tubercles, and like these tending 



SYPHILIS. 



241 



rapidly to undergo caseous degeneration and liquefaction or suppura- 
tion. When superficial, they speedily form unhealthy-looking ulcers. 
When deeper seated they become converted into abscesses, which then 
gradually enlarge and ultimately burst. The tubercles vary from the 
size perhaps of a pin's head to that of a pea or bean. It is to their 
development in connection with the mucous membrane of the nose that 
the peculiar symptoms referable to this organ are due. They also form 
in the mouth and fauces, in the larynx, trachea, and bronchial tubes; 
and they appear in the substance of the lungs, producing a condition 
not unlike that of ordinary lobular pneumonia, and often inducing 
pleural inflammation. The cutaneous eruption is due to the formation 
of these tubercles in the skin ; and the subcutaneous lumps and ab- 
scesses, and those which develop themselves in the substance of muscles, 
are of the same nature. The kidneys, spleen, testicles, and other organs 
are also occasionally affected. Implication of the lymphatic glands is 
not unfrequent, but must be regarded as generally, if not always, 
secondary to specific lesions occurring in parts with which they are 
connected. More or less of simple inflammation is generally associated 
with the specific lesions. 

Treatment. — It is impossible to lay down any authoritative rules for 
the treatment of equinia. No specific is known, and no drug which 
has any favorable influence over its course. Iodine, arsenic, and 
strychnia have each been recommended. All that can be done, prob- 
ably, is to support the patient by nourishment, stimulants, and tonics, 
to relieve pain and other symptoms, and to cleanse and treat with 
stimulating or astringent lotions, or other applications, the nasal mu- 
cous membrane and other inflamed and ulcerated parts. During con- 
valescence change of air and good diet are of course important. 



SYPHILIS. 

Definition. — A specific disorder, communicable by inoculation only, 
resembling the exanthemata, in the facts that it presents a period of 
latency, and a period during which characteristic eruptions make their 
appearance, and that one attack confers protection, but differing from 
them in the remarkably long duration of these periods, and in the 
tendency to the recurrence, it may be for many years, of specific 
lesions. 

Causation and History. — Syphilis has occasionally prevailed in the 
form of widespread and severe epidemics. One such epidemic passed 
through Europe during the latter part of the fifteenth century, and it 
was probably in great measure owing to this fact that, for a time, it 
came to be assumed that the disease first made its appearance in Eu- 
rope after the discovery of America, and had been imported from that 
continent. There is no doubt, however, that this was an erroneous 
assumption, and that, just as syphilis prevails now, so it has prevailed 
from the earliest times both in Europe and in the other quarters of the 

16 



242 



SPECIFIC FEBRILE DISEASES. 



Old World. Like many other diseases, syphilis was long confounded 
with affections which, though often associated with it, or arising under 
analogous circumstances, are essentially distinct from it. Hunter re- 
garded gonorrhoea as one of its manifestations, and even until quite 
recently other forms of circumscribed inflammation of the surface of 
the genital organs have been confused with the true chancre — the sore 
which arises at the point of syphilitic inoculation. But, thanks to the 
labors of Ricord and of other recent observers, including Mr. Henry 
Lee, the phenomena of syphilis have now apparently been fully dis- 
entangled from those of the maladies which simulate it, and our knowl- 
edge of syphilis is as accurate as is our knowledge of scarlet fever or 
of small-pox. The symptoms of syphilis are quite characteristic, and, 
when fully developed, can rarely escape ready recognition, yet the dis- 
ease, though maintaining its identity and its typical features, has varied 
very greatly in its virulence at different times and in different coun- 
tries, under circumstances the nature and relative importance of which 
it is not easy to estimate. Of the specific nature of syphilis, therefore, 
there can be no doubt. There is equally no doubt that it spreads by 
means of a specific contagium, and that there is no evidence to show 
that it ever originates spontaneously. The specific poison of syphilis 
is never imparted, like that of typhus, by atmospheric conveyance, or, 
like that of cholera, by means of diffusion through water, it acts only 
when directly introduced by inoculation. For the most part, as is well 
known, it is imparted in the act of sexual intercourse by the secretions 
which are furnished by primary or secondary sores — the thin cuticular 
covering of the glans penis and inner surface of the prepuce, and the 
mucous membrane of the urethra, and the corresponding parts in the 
female, becoming readily inoculated even when no breach of surface 
exists. It is also not unfrequently transmitted from the sucking child 
to its nurse, or from the nurse to her suckling, either from the mucous 
membrane of the mouth to the nipple, or conversely, or from mouth 
to mouth. But, indeed, inoculation may take place at any part, pro- 
vided only the cuticular layer be not too thick, or there be an excoria- 
tion or a wound — thus syphilis has not unfrequently been accidentally 
inoculated on the hands of medical men, and occasionally has been im- 
parted by the operation of vaccination. And lastly, it is a common 
thing for syphilitic parents to procreate children who are also syphilitic. 
Thus a syphilitic mother may have a syphilitic child, the father re- 
maining uncontaminated, or a syphilitic father may beget a syphilitic 
child, and may infect the mother, either directly or indirectly, through 
the foetus. The contagium of syphilis resides in its most virulent form 
doubtless in the primary syphilitic sores, and in the indurated glands 
which succeed to them, but the contagious influence persists during the 
secondary phenomena of the disease, and also during the period of so- 
called " tertiary " manifestations, as is distinctly proved by the fact 
already adverted to, namely, the transmission of the disease in the 
later stages from parents to their offspring, and from these to healthy 
wet-nurses. Experiments have been made which seem to prove that 
the blood of syphilitic patients possesses contagious properties, but 
there can be no doubt that, as well in the later as in the earlier stages 



SYPHILIS. 



243 



of the disease, the virus is mainly concentrated in the specific lesions. 
It may be added that the secretions of syphilitic patients have been 
supposed to possess infectious properties, more especially the milk, the 
semen, and the products of the mucous surfaces. But Mr. H. Lee is 
probably right when he insists that those organs only yield infectious 
discharges which are either distinctly implicated in the syphilitic pro- 
cess, or are in a condition of inflammation. The protective influence 
of one attack of syphilis has only been fully recognized since the true 
disease has been disencumbered of the maladies which had grouped 
themselves with it. It is now established beyond doubt that syphilitic 
inoculation affords as secure a protection against subsequent attempts at 
inoculation as does one attack of small-pox or scarlet fever against 
subsequent attacks of either of these affections ; that a person fully 
under the influence of the syphilitic poison, or who has had an attack 
from which he has recovered, very rarely indeed acquires a chancre, 
even when inoculated under the most advantageous circumstances, and 
even more rarely suffers in consequence from the secondary symptoms 
which so surely follow on the primary inoculation ; and further, that 
a person inoculated a second time, during the period which elapses be- 
tween a primary inoculation and the maturation of the primary chancre, 
has, as the result of his second inoculation, a modified chancre — a chan- 
cre which runs its course with exceptional rapidity, and attains its full 
development concurrently with its elder brother. 

Symptoms and Progress. — 1. Primary Symptoms. When a successful 
inoculation has been effected on a person who is unprotected, the virus 
remains apparently quiescent for a period of uncertain duration, but 
which is estimated by Lancereaux at from eighteen to thirty-five days, 
with a mean of twenty-eight days. At the end of that time a minute 
dusky red papule makes its appearance, which is unattended for the 
most part with either pain or itching, and slowly enlarges. Soon a 
thin grayish crust, the result of superficial necrosis, appears on its most 
prominent part. And whilst the papule gradually increases in area, 
successive crusts are formed and shed from its surface, which thus 
becomes more and more eroded ; so that before long the papule, which 
has now become a tubercle, presents an elevated dusky red margin 
surrounding a cupped excavation, with a gray, dry surface. Almost 
from the beginning the papule presents a remarkable indurated char- 
acter and appears imbedded, as it were, in the substance of the skin. 
These characters it retains, the induration extending a little beyond 
the area of elevation, and presenting a very obvious edge, so that the 
mass can be readily grasped between the finger and thumb. At the 
end of about six weeks the tubercle has attained its complete develop- 
ment, and is perhaps of the size of half a pea or somewhat larger. It 
then begins slowly to subside, and after awhile cicatrizes, generally, 
however, leaving behind more or less induration, more or less depres- 
sion, and more or less dusky discoloration. This is the course of the 
true Hunterian chancre. But, just as the inoculated cow T -pox vesicle 
presents many deviations from its natural course, so does the pimple 
which results from syphilitic inoculation. For a description of these 
reference must be made to surgical works. It should be stated, how- 



244 



SPECIFIC FEBRILE DISEASES. 



ever, that inoculation may take place without the development of any 
appreciable local sore, and that a sore may have existed and yet no 
visible cicatrix remain. A week or two, usually, after the first appear- 
ance of the chancre, the lymphatic glands in relation with the affected 
part begin to enlarge. If, therefore, the chancre is on the genital 
organs the enlargement occurs in the glands of one or both groins. 
The enlargement is slow and painless. For the most part several 
glands are affected, and each probably attains the size of an almond 
shell. They remain freely movable under the integuments, and are 
characterized, like the chancre itself, by extreme induration. They 
rarely undergo suppuration, but remain with little change for months 
or years. The period, of which the phenomena have just been briefly 
described, corresponds to the period of incubation or latency of the 
exanthemata ; it corresponds accurately to that period in the inoculated 
small-pox during which the primary pustule attains maturity, and 
which precedes the general variolous outbreak. 

2. Secondary Symptoms. — From six weeks to three months after 
inoculation, generally perhaps between sixty and seventy days, the 
eruptive stage, the stage of secondary symptoms, supervenes. The in- 
vasion of this stage is often indicated by slight febrile symptoms, 
attended with more or less obvious, recurring exacerbations, increased 
frequency of pulse, loss of appetite, weakness and emaciation, cachexia, 
restlessness, want of sleep, and pains more or less variable but aug- 
menting towards night in the head, joints, and back. Shortly after- 
wards, or sometimes concurrently with the febrile disturbance, symp- 
toms of a more characteristic kind manifest themselves. Among the 
earliest of these are certain affections of the skin and mucous mem- 
branes, and inflammations of the joints, bones, and eyes. The cutaneous 
affection for the most part consists in the first instance of a roseolous 
eruption, which generally appears first on the trunk, but before long 
manifests itself on the face, extremities, and also on the palms and 
soles. It is in the beginning a mere subcutaneous rash of roundish 
dusky-red spots, varying from one to two or three lines in diameter, 
and fading at the edges. But they soon become slightly elevated and 
lenticular in form. They are variously scattered, and are not unfre- 
quently grouped in segments of circles or in circles. The rash comes 
out in successive crops, and may continue off and on for some two or 
three months. In association with it the hair not unfrequently be- 
comes dry and loses its gloss, and presently begins to fall out ; and 
thus more or less complete baldness is apt to ensue. This roseola is 
sometimes the only rash which makes its appearance, but very com- 
monly it constitutes the first stage of some other variety of skin 
disease. Thus sometimes the individual roseolous spots, or the patches 
formed by the coalescence of several, gradually enlarge, and fading 
away in the centre form circles or irregularly rounded marginated 
tracts of erythema circinatum ; sometimes as they enlarge they become 
covered with thin scales, and- acquire a close resemblance to lepra or 
psoriasis ; sometimes they assume the form of distinct but flat tubercles ; 
sometimes they become the seat of vesicles or bullae, and occasionally 
even of pustules. And thus the secondary eruption may present an 



SYPHILIS. 



245 



erythematous, a scaly, a papular or tubercular, a vesicular or a pustular 
condition, or may present several or all of these characters at. the same 
time variously combined. But besides this peculiar polymorphous 
character, which is itself indicative of syphilis, there are generally 
certain peculiarities about the eruption which, apart from all other 
considerations, indicate its specific character. Thus, in the first place, 
it often presents a peculiar dusky-red or coppery tint, and this hue 
tends to persist long after the actual eruption has disappeared. It is 
due to some pigmentary deposit in the substance of the cutis; and it is 
worth while to remark that occasionally also the course of the super- 
ficial veins in the extremities, and especially in the legs, becomes indi- 
cated by similar dusky pigmentary stains. This condition, however, 
is not peculiar to syphilis. In the second place, syphilitic eruptions 
have a peculiar aptitude to affect those parts which the non-specific 
eruptions they resemble specially avoid; they are common on the 
flexor aspects of the joints, about the forehead, where they often cause 
the so-called "corona veneris," and especially in the palms and soles. 
It may be added that, in syphilitic lepra, the formation of scales is 
usually much more scanty than in the non-specific variety of the dis- 
ease; that it is almost impossible to make any real distinction between 
the several syphilitic affections of the palms and soles, inasmuch as all 
are generally attended with desquamation ; and further that scabs, due 
apparently to the interstitial effusion of serum or of pus, sometimes 
form on the leprous or tubercular patches, and lead by easy gradations 
to the truly vesicular and pustular conditions. 

The morbid processes of the mucous membrane first show themselves 
in the fauces and pharynx, generally upon the tonsils. On these latter, 
which then present an inflammatory blush, shallow ulcers, for the 
most part reniform in shape, make their appearance ; they are generally 
unattended with pain or even uneasiness, and disappear after a few 
weeks' duration. Similar sores are also apt to appear on the palate 
and on the internal surface of the cheeks, on the tongue and lips. In 
addition to these, condylomata or mucous tubercles often become de- 
veloped both in the mouth, fauces, and pharynx, about the anus, upon 
the mucous or delicate cuticular surfaces of the genital organs, and in 
those parts of the skin which are in constant apposition and conse- 
quently always moist. Mucous tubercles are roundish, oval, or more 
or less irregular congested tabular elevations, not fibrous, warty, or 
villous, but uniform in texture and soft, with a tendency to be covered 
with a grayish or yellowish film, to exude abundant moisture, to se- 
crete pus, or to undergo ulceration. Similar formations may be de- 
veloped within the rectum, oesophagus, nose, larynx, trachea, and 
bronchial tubes, and not improbably in other of the mucous tracts. 

The pains in the joints and bones are of a rheumatic character, and 
are apt to become especially severe at night. There may be no visible 
change in the parts affected ; sometimes, however, there is more or less 
obvious periostitis, or more or less obvious arthritis and effusion into 
the joints. True nodes, however, are comparatively rarely developed 
at this time. 

The affections of the eye are twofold. The most obvious is a form 



216 



SPECIFIC FEBRILE DISEASES. 



of iritis, attended with little pain, uneasiness, or intolerance of light, 
but with more or less of the ordinary form of sclerotic injection which 
accompanies iritis. Exudation of rust-colored lymph occurs at the 
surface of the iris, mainly, however, at its internal margin, and, though 
much less frequently, at its outer margin. In the former situation the 
lymph may form a uniform tumid ring, and in either of them a series 
of reddish beads. At the same time the iris becomes sluggish or im- 
movable, and probably adheres to the surface of the lens, and the 
aqueous humor gets turbid and yellowish from the admixture with it 
of inflammatory products. The less obvious but more serious form is 
retinitis, coming on insidiously without external congestion, pain, or 
intolerance of light, but marked by increasing haziness of vision and 
indications of retinal congestion and extravasation. 

3. Tertiary Symptoms. — The period of secondary symptoms, after 
lasting for a few weeks or months, terminates for the most part in 
spontaneous convalescence ; and the patient may possibly remain hence- 
forward free from disease. More commonly, however, after the lapse 
of a variable period, generally from six months to two years, but some- 
times after twenty years or more, other characteristic lesions manifest 
themselves, distinctly referable to the syphilitic poison, and usually 
termed tertiary symptoms. It must be added that, although there is 
generally a distinct interval between the subsidence of the secondary 
and the onset of the tertiary symptoms, they do occasionally, and per- 
haps not unfrequently, become intermingled, or pass without break one 
into the other. The chief characters by which tertiary symptoms are 
distinguishable from those of earlier occurrence are, 1st, their depend- 
ence, for the most part, on a specific overgrowth of tissue — the forma- 
tion of gummata ; 2d, their great inveteracy and tendency to recur ; 
3d, their involvement of internal organs as well as of such as are 
superficial ; and 4th, their want of symmetry. We will consider the 
more important of these lesions seriatim, and in reference to the organs 
which they affect. 

Skin. — The most common form of skin disease is that which de- 
pends on the appearance of dusky red or coppery flat tubercles, which 
differ little, if at all, in the first instance, from those which have been 
described among the secondary symptoms ; they are, however, gener- 
ally larger, more prominent, and more indurated, and occur sometimes 
irregularly scattered, sometimes collected into irregular groups, some- 
times arranged in the form of crescents, circles, or sinuous lines. In 
the first case they gradually increase in number and coalesce; in the 
second, the groups tend to increase in area, and not unfrequently in 
thickness also, so as to form irregular tuberculated elevations of con- 
siderable extent and thickness; in the last case the affection tends to 
spread centrifugally, slowly invading the healthy surface by a line of 
ever new tubercles, while the parts primarily affected return to a state 
of comparative health. In some instances the tubercles become scaly 
on the surface, and in that case the affection presents a certain amount 
of resemblance to some forms of lepra ; in other instances they undergo 
superficial molecular necrosis, they become more or less deeply eroded, 
and a scab forms without a vesicle or pustule having ever been de- 



SYPHILIS. 



247 



veloped; in other cases each papule undergoes suppuration, and a thick 
adherent ecthymatous scab results; and, lastly, ulceration is not unfre- 
quent. But whichever of these processes takes place, the disappear- 
ance of the active lesion is followed by the formation of indelible de- 
pressed cicatrices ; and the progress of the serpiginous form can always 
be traced by the cicatricial surface which it leaves in its wake, and the 
pre-existence of large patches always recognized by the persistence of 
a corresponding cicatrix. The tubercular eruptions here referred to, 
although essentially identical with one another, are often denominated, 
according as one or other peculiarity predominates, tubercular, pustu- 
lar, or serpiginous syphilide, or syphilitic lupus, or psoriasis. They 
affect almost any part of the body, but are perhaps especially common 
on the face, on the neck and shoulders, on the buttocks and extremities. 
When they occur, as they frequently do, on the palms and soles, there 
is little to distinguish them from secondary lepra. Another well- 
marked form of skin-affection is that known by the name of syphilitic 
rupia. It consists in the formation, indiscriminately on various parts 
of the body, of scanty and isolated blebs, each of which arises on a 
congested indurated base, and may attain the diameter of a fourpenny- 
piece. Their contents are clear and limpid, or turbid and sanious, and 
soon concrete into scabs, each of which, from constant additions to its 
edges and base, rapidly attains large dimensions — a thickness, for ex- 
ample, varying from a quarter to three-quarters of an inch, and a form 
which may resemble that of a limpet-shell or of an oyster-shell, or may 
be merely irregular and rocky. The base at the same time becomes 
deeply excavated ; and on removing the scab a deep unhealthy slowly 
healing ulcer is revealed. These rupial sores leave remarkably deep 
cicatrices. 

Very frequently, altogether independently of any primary cutaneous 
disorder, hard nodules, from the size of a pea to that of a filbert, appear 
singly or in groups in the substance of the subcutaneous connective 
tissue. They are unattended with pain, and very slow in their prog- 
ress ; but after awhile adhere to the skin, which then becomes some- 
what prominent over them, assumes a dusky red tint, and gives a sen- 
sation to the finger of elasticity and resistance, or of " bogginess." 
Before long the central portion of the involved skin becomes perforated 
in one or more points, and a viscid, turbid, or sanious fluid escapes 
together with shreds or a mass of subcutaneous slough. In this way a 
deep cavity results, the boundaries of which are formed of ragged 
grayish or yellowish tissue. If groups of such masses soften, we get a 
number of such cavities side by side, the skin appears irregularly 
honeycombed, and the bridles which intervene between the contig- 
uous openings become undermined by the coalescence - beneath them of 
the contiguous cavities. Thus extensive and deep destruction of skin 
and of subcutaneous connective tissue takes place, which is very slow 
of repair, and followed by deep cicatrices. 

Mucous Membranes. — The affections of the mucous surfaces have 
much resemblance to those of the skin. They are chiefly superficial 
and tubercular, or submucous and gummatous. The former are espe- 
cially frequent in the tonsils, fauces, soft palate, pharynx, tongue, and 



248 



SPECIFIC FEBRILE DISEASES. 



other parts of the mucous surface of the oral cavity ; are followed by 
deep unsymmetrical and obstinate ulceration ; and lead, as in the skin, 
to extensive destruction with permanent loss of tissue and contraction. j 
Thus, the uvula and soft palate may be more or less perfectly destroyed ; 
or the isthmus of the fauces may be narrowed, or stricture of the j j 
oesophagus may ensue ; or destruction of the epiglottis, vocal cords, or 
various other parts of the cartilaginous skeleton of the air-passages 
may take place; and following upon these several lesions, loss of 
voice, difficulty of swallowing or breathing, and other serious or fatal j 
consequences. Gummatous tumors also appear in these several parts, 
frequently in the tongue, where they may form a mass as large as a 
hen's egg, and sometimes in the connective tissue and muscles of the 
larynx. These not unfrequently assume many of the superficial 
characters of epithelioma, and undergo the same processes as do subcu- 
taneous gummata. Similar affections to the above take place in the 
male urethra and in the vagina and os uteri, as well as in the ex- 
ternal parts of the organs of generation of both sexes ; they occur also 
within the anus and in the lower part of the rectum; and may, in all 
of these situations, in addition to other forms of mischief, lead ulti- 
mately to more or less serious contraction or stricture. 

Organs of Locomotion. — Muscular tissue is affected occasionally in 
the same way as the subcutaneous connective tissue. Gummatous 
growths invade its texture, separating from one another its fibres, 
which then undergo degeneration. Such formations occur quite irregu- 
larly and may be mistaken for growths of a far more serious character. 
We have already pointed out that such tumors may form among the 
muscles of the larynx; they have also been observed implicating the 
masseter, the muscles of the scapula, and those indeed of most other 
parts. The bones are sometimes affected with more or less diffused 
periostitis; but more commonly nodes are developed on various parts 
of the long or flat bones, including the ribs and sternum and bones of 
the face and skull. Nodes consist in gummatous growths in connec- 
tion chiefly with the periosteum. They are usually extremely painful 
and tender, of various extent and prominence, more or less hard and 
unyielding at the periphery, but more or less elastic or even fluctuating 
in the centre. They rarely end in suppuration, and generally heal 
with more or less resulting irregularity. But although nodes do not 
usually result in the destruction of the bone which they affect, such is 
not always the case. A frequent cause of destruction of bone has been 
already adverted to, namely, the extension of syphilitic ulceration in 
depth until the subjacent bone is exposed. In one or other of these 
modes necrosis or caries of bone may occur at any part. But they are 
especially common in connection with the bones of the nose, palate, 
and skull, and with the cartilages of the larynx and trachea. The 
bones of the ear may also thus suffer. Syphilitic affections of the 
bones of the skull are generally limited to the outer surface and the 
diploe, but occasionally involve the inner table as well, and are then 
apt to cause more or less serious cerebral symptoms. The joints also 
occasionally suffer, the surrounding soft parts becoming much thick- 
ened and infiltrated, and the cavities distended with fluid effusion. 



SYPHILIS. 



249 



Testes. — These become infiltrated with syphilitic growth and much 
enlarged, and not nn frequently hydrocele occurs at the same time. 

The lymphatic glands generally become, to some extent, enlarged 
and indurated secondarily to local syphilitic lesions ; but sometimes 
also they become, here and there, in groups, so enormously hypertro- 
phied as to simulate the enlargement of these organs due to scrofula, 
lymph adenoma, or cancer. 

Internal Organs. — The affections of the internal viscera are scarcely 
so well known as those of the organs which have been already consid- 
ered, but they are even more serious. The liver is perhaps their most 
frequent seat. The chief conditions which have been recognized here 
are, first, a more or less general hyperplasia of the connective tissue, 
especially of the capsule of Glisson, leading on to a form of cirrhosis; 
and, second, the formation of gummy tumors which rapidly undergo 
degeneration, and by their contraction cause puckering and Assuring 
of the surface of the organ. Either of these conditions may lead to the 
development of symptoms identical with those resulting from ordinary 
cirrhosis. The organs of circulation are also frequently implicated. 
The muscular tissue of the heart is occasionally the seat of diffuse 
fibroid infiltration or of more or less extensive gummatous formations, 
exactly like those involving the voluntary muscles. These induce de- 
generation of the tissue, induration, adhesion of pericardium, and the 
ordinary symptoms of progressive cardiac incompetence. There is 
good reason also to believe that some forms of arterial disease, that 
form especially in which the inner coat undergoes a kind of nodular 
hypertrophy antecedent to the supervention of degenerative changes, 
are in many cases the result of syphilis. It is at all events certain 
that arteries frequently assume this condition in those who are the 
subjects of syphilis, and who are suffering from gummatous tumors in 
other organs. And it is also certain that some of the lesions observed 
iu the brains of syphilitic patients are essentially due to arterial 
changes of this kind associated with obstructive thrombosis. Syph- 
ilitic affections of the lungs (gummata and fibroid infiltration) are 
described ; nevertheless, their recognition is attended with much ob- 
scurity. We have already shown that the bronchial tubes, like the 
larynx, may be distinctly implicated. But besides bronchial lesions 
there are not unfrequently found in the lungs of old syphilitic patients 
scattered masses of hard grayish or blackish induration, or caseous 
masses imbedded in such tracts of induration, which, although in many 
particulars resembling affections of tubercular or inflammatory origin, 
are almost certainly gummata. The most grave of all tertiary syphi- 
litic affections are those which involve the nervous centres; gumma- 
tous tumors are developed sometimes in connection with the inner 
layer of the dura mater, sometimes in connection with the pia mater, 
or the connective tissue of the brain-substance. In the latter two 
cases the growths, which may attain the size of a pigeon's egg or even 
of a hen's egg, are for the most part, even if of peripheral origin, im- 
bedded in the substance of the brain. Their most frequent site is the 
basal portion. Similar growths occur, though much less frequently, 
in connection with the spinal cord. The symptoms due to them are 



250 



SPECIFIC FEBRILE DISEASES. 



those of cerebral or spinal tumors. The cranial nerves and even the 
brain-substance are occasionally the seats of syphilitic infiltration. 
Specific affections of the kidneys have been less thoroughly investi- 
gated ; nevertheless, it is certain that these organs are sometimes 
affected, sequentially to syphilis, with diffused inflammatory processes, 
which induce atrophy, and that they are sometimes studded with dis- 
tinct gummata or with patches of cicatricial tissue, attended with cor- 
responding linear or stellate contractions of the surface, and having im- 
bedded within them small caseous masses. It must be added that 
probably all other organs are liable in some degree to syphilitic disease. 
Among them must especially be noted the mamma?, the ovaries, the 
organs of sense, and the stomach and other parts of the alimentary canal. 

The effects of syphilis do not end here. The long persistence of 
tertiary symptoms, with their frequent tendency to relapse, leads 
gradually but surely to a marked cachectic state of the system, indicated 
by sallowness and anaemia, with relative increase of white corpuscles, 
emaciation and loss of strength, and lardaceous or amyloid degenera- 
tion of the liver, spleen, kidneys, and other parts, together with the 
additional symptoms to which such complications give rise. And 
finally may follow tuberculosis, or insidious but non-specific inflam- 
mations of various internal organs. 

4. Inherited syphilis presents some peculiarities which make it neces- 
sary to give the subject a brief separate consideration. It may be de- 
rived either from the father or the mother, or from both. The effects 
of parental syphilis are not unfrequently manifested in the death of the 
foetus, and consequent abortion, at the latter period of pregnancy. The 
child is born dead, and more or less decomposed, but. usually without 
distinct evidence of specific taint. In some instances the placenta is 
affected with syphilitic disease. In other cases the infant is born alive, 
but shrivelled, puny, and unhealthy-looking, and large bulla? appear 
on the palms of the hands, or on the wrists, or on the corresponding 
parts of the lower extremities. These blebs give rise to unhealthy 
sores, and the infant almost invariably dies speedily. In the majority 
of cases, however, the babe appears to be healthy at birth, and first 
gives evidence of disease after an interval of three or four weeks. The 
symptoms are mainly those of the secondary period of acquired syphilis; 
but there are some features which are specially characteristic and im- 
portant, and to these alone attention will now be drawn. Among the 
earliest of these are congestion and swelling of the nasal mucous mem- 
brane, with abundant secretion, giving rise to snuffles and other symp- 
toms of chronic coryza, diffuse inflammation of the mouth and fauces 
with sores at the angles of the mouth, mucous tubercles about the anus 
and similarly constituted parts, and a roseolous rash. The rash is gen- 
erally most abundant on the buttocks, privates, and neighboring parts 
of the abdomen and thighs, on the face, and on the palms and soles. 
It consists sometimes in circular patches from a line to half an inch in 
diameter and of lenticular form, sometimes in nearly similar patches, 
which, however, are slightly concave or cupped, and present therefore a 
more or less tumid marginal ring. They vary in color, are sometimes 
dusky red, sometimes brown or yellow, sometimes of a more or less 



SYPHILIS. 



251 



coppery tint. They are sometimes smooth on the surface, sometimes 
scaly, and sometimes present superficial excoriation or erosion. The 
eruption on the palms and soles assumes a scaly character, and is 
attended with a tendency to crack and exfoliate. In association with 
these symptoms the child becomes emaciated, its face assumes an old 
and weird character, its complexion grows sallow and unhealthy-look- 
ing, its skin dry and shrivelled, its hair scanty and thin, and not ui> 
frequently it suffers from diarrhoea. These symptoms last probably for 
a few months, and have generally disappeared by the end of the first 
year. Somewhat later, generally from the age of four or five up to that 
of puberty, the tertiary series of symptoms manifest themselves. These 
differ little from those which characterize the common tertiary stage. 
There are two or three however of peculiar and special interest, which 
now become apparent or develop themselves for the first time. One 
of them is flattening of the bridge of the nose, from sinking in of the 
subjacent cartilages. Another is enlargement of the lower end of the 
humerus between the epiphysis and shaft. A third is a peculiar form 
of atrophy of the permanent incisor and canine teeth. This is gener- 
ally most marked in, and is often limited to, the two upper central 
incisors ; they are atrophied, peglike, and present towards their free 
edge a reniform or cordate character, — the notch occupying the centre 
of this edge. This condition is traceable to the effect on the tooth- 
germs of the stomatitis from which the children have previously suffered. 
The last of them is interstitial keratitis, that is, an interstitial inflam- 
mation of the cornea, marked by increasing cloudiness and opacity of 
the part, and attended with a vascular zone in the sclerotic, and more 
or less intolerance of light. There is no vesication or ulceration, and 
the opacity speedily diminishes under appropriate treatment. The 
recognition of the last two affections is due to Mr. J. Hutchinson. 

It would be impossible in a brief space to discuss the differential 
diagnosis of syphilis. It must be sufficient to say that the manifesta- 
tions of syphilis simulate a vast range of different diseases; and further, 
that syphilis necessarily often occurs in persons who are the subjects 
of skin-affections and various other disorders, and often exerts a modi- 
fying influence over them; and that hence it is frequently quite impos- 
sible to form an exact diagnosis, without fully going into the history 
of the patient's case, and taking into careful consideration all the facts 
of his past history and present condition. 

Morbid Anatomy and Pathology. — In the foregoing description of the 
phenomena and sequela? of syphilis we have necessarily, to a large ex- 
tent, discussed the pathological processes of the disease and its morbid 
anatomy. It remains, however, to give a brief connected account of 
these subjects. The morbid poison which enters the system at the time 
of inoculation is doubtless a living entity or contagium, which imparts 
specific properties primarily to the growth which it directly induces, 
and secondarily to the vital constituents of the enlarging lymphatic 
glands situated next above that growth. Possibly from the primary 
sore, more probably, however, from the group of morbid lymphatic 
glands, as a centre, is shed into the blood-stream newly manufactured 
contagious matter (probably particulate) ; which in its turn infects in 



252 



SPECIFIC FEBRILE DISEASES. 



different proportions and in different order the various organs and 
tissues of the body, producing in them specific processes which have a 
more or less close resemblance to those out of which they arise, and 
which like them are infectious certainly to other persons, and probably 
like carcinoma to the individual. The early series of general phenom- 
ena (those for the most part which belong to the period of secondary 
symptoms) differ scarcely at all in their anatomical characters and in 
their local results from simple inflammatory processes. There is con- 
gestion, proliferation of connective tissue imitative of granulation- 
tissue, and a tendency in the new formation, after a temporary per- 
sistence, to subside altogether so as to leave no trace whatever behind, 
or to merge into the tissues, in connection with which it appears — if in 
connection with connective tissue into connective tissue, if in connection 
with bone into bone, if in the matrix of the- liver, kidney, lung, testicle 
or brain, to be converted into nucleated fibrous tissue, and to produce 
therefore in these organs induration, contraction, and atrophy. The 
later phenomena (those which belong chiefly to the tertiary stage) con- 
sist in the formation of adventitious growths, termed gummata, which 
are identical in structure with primary chancres and the primarily in- 
durated glands. They consist like them of cell-growth, differing little 
microscopically from ordinary granulation-tissue, and in this respect 
therefore little from the secondary lesions, but presenting certain special 
features. Thus, they do not so much displace as infiltrate or involve 
the tissues among which they arise; they have a remarkable tendency 
to undergo speedy caseous degeneration, and to cause molecular or fatty 
disintegration of the higher elements which are mixed up with them; 
if developed in internal organs, they acquire for the most part perma- 
nence as either caseous lumps, earthy concretions, indurated fibrous 
patches, or morbid tracts in which all of these conditions are variously 
combined ; and if they be developed in superficial parts, such as the 
skin, mucous membranes or superficial bones, their degeneration results 
in the formation of crusts, ulcers, abscesses or sloughs, with more or 
less serious destruction of tissue. Gummatous tumors, while in process 
of development, vary in their physical characters; thus, sometimes they 
are grayish, firm, and translucent or opaque; sometimes (especially 
when they form beneath the skin and mucous membranes) are infil- 
trated with a mucus-like fluid, which oozes away when they are natur- 
ally or artificially opened. 

There is undoubtedly a resemblance both anatomically and func- 
tionally (at all events as regards their infectiveness) in all the 
congestive or proliferating lesions which depend for their origin on the 
syphilitic virus. And although a line may be drawn, both on clinical 
grounds and for the purposes of description, between secondary and 
tertiary phenomena, and although it is quite true that the later lesions 
are far more serious and virulent than those which precede them, 
there is no doubt that they pass one into the other, that they shade off 
the one into the other by numerous gradations, and that they are often 
blended ; so that while, on the one hand, gummatous tumors may 
occur during the secondary period, secondary eruptions may be met 
with late in the progress of the disease. 

Treatment. — For the prophylactic treatment of syphilis, and for the 



SYPHILIS. 253 

treatment of the primary affection reference must be made to surgical 
works. The inoculation of syphilis upon healthy persons, which has 
been so extensively practiced by Boeck, and advocated by others, in 
order that by giving them the disease it might affect them in a mild 
form and prevent any future attack in a graver form, seems to us, we 
confess, not only dangerous but altogether unjustifiable. It is now 
generally admitted that syphilis, like other specific febrile diseases, is 
incapable of absolute cure, and that it will run a definite course in 
respect of duration, no matter what steps are taken to arrest its 
progress. It is nevertheless certain that we have two remedies, at 
least, which exert a remarkable influence over its various localized 
manifestations, which subdue them almost to zero if they do not abso- 
lutely annul them, and which keep the general disease in abeyance 
even if they fail (as they probably do) to extinguish it utterly. These 
remedies are mercury and iodine in their various preparations. The 
value of mercury was early established, and has only lately, indeed, 
been regarded with suspicion. But this suspicion arose doubtless out 
of the injurious influences which the abuse of mercury engendered 
during the earlier part of this century, and was supported by the rec- 
ognition of the fact that the free use of mercury failed in many cases 
to prevent the supervention of secondary symptoms. It is admitted 
now that mercury does not prevent either secondary or tertiary symp- 
toms from coming on ; but nevertheless it is certain that it has a mar- 
vellous influence in causing the removal in turn both of the primary, 
secondary, and tertiary lesions of the disease. The form, the dose, the 
mode, and the length of time in which the drug should be adminis- 
tered are points on which there is much difference of opinion. Some 
prefer to introduce it by the inunction of strong mercurial ointment on 
the inner aspect of the thigh or other parts in which the integuments 
are thin : in this case from half a drachm to a drachm of the ointment 
may be rubbed in every night before the fire. Others affect the prac- 
tice of fumigation by means of volatilizing calomel with the heat of 
boiling water. The drug may by this means be inhaled, or applied 
to the general surface, or to particular regions with little difficulty. 
For inhalation, not more than four or five grains of calomel should be 
employed. Others again recommend that the mercury should be ad- 
ministered by the mouth. For this latter purpose any mercurial 
preparation in an appropriate dose is applicable. But the most con- 
venient, and possibly the best, is corrosive sublimate or the red iodide 
of mercury in doses of from to f gr. about three times a day, or 
equivalent proportions of the liquor hydrargyri perchloridi. The 
treatment should be continued until the lesions have disappeared under 
its influence, and even for a week or two longer, and the quantity 
should be regulated by its effects on the system, slight soreness of the 
gums only being maintained. Iodine is almost equally valuable with 
mercury ; but it seems to have a special value during the later periods 
of the disease, in which (when the lesions prove intractable) it may 
often be beneficially combined with the mercurial treatment. The 
usual and probably on the whole best form is the iodide of potassium 
in from 5 to 10 grain doses three times a day, combined with a tonic. 



254 



SPECIFIC FEBRILE DISEASES. 



[Cases will, however, be occasionally met with in which it will be 
necessary to prescribe much larger doses than these. In cerebral 
syphilis, for instance, it will frequently happen that marked improve- 
ment will follow the administration of half a drachm three times a 
day, in cases in which 10-grain doses have failed to produce the 
slightest effect. Moreover, these large doses are perfectly well borne, 
the patient often growing fat while taking them.] The syrup of the 
iodide of iron is in many cases, especially those of young children, 
very valuable. Bromine has an antisyphilitic power similar to that of 
iodine, and is sometimes substituted for it. Among other anti- 
venereal remedies which have acquired and still enjoy a wide reputa- 
tion are sarsaparilla and nitric acid in large doses. They have 
probably no specific virtues at all. Tonic medicines — quinine, iron, 
cod-liver oil, and the like — are often of immense value in the treatment 
of the cachexia which attends the later stages of the disease. The 
value of local remedies in the treatment of syphilitic lesions is un- 
doubted : the most valuable are the mercurial and the iodic, among 
which may be enumerated powdered calomel, black-wash, mercurial, 
citrine or iodine ointment, iodide of starch paste, and localized calomel 
fumigations, one or other being employed according to the nature of 
the lesion and the convenience and relative safety of its applicability. 



PYAEMIA. (Septicemia.) 

Definition. — By the term " pyaemia " is understood a febrile and for 
the most part acute disorder, due to the entrance into the blood of 
certain poisonous, probably inflammatory, products, and characterized 
usually by the blocking up by clots or emboli of the arterioles of the 
lungs and other organs, and the consequent occurrence therein of scat- 
tered patches of congestion, haemorrhage, inflammation, suppuration, or 
gangrene. 

Causation. — The conditions out of which pyaemia arise are very 
numerous and various. First, it is a frequent sequela of accidental 
injuries, such as burns, scalds, bruises, and lacerations, and of com- 
pound fractures, especially of the long bones, and of the bones of the 
head and pelvis. Second, it frequently ensues on surgical operations, 
especially those which are attended with the formation of extensive 
raw surfaces, such as amputations of the larger limbs, and those also 
involving bone, bladder, prostate, urethra, or rectum. To these must 
be added operations on veins, such as phlebotomy and operations for 
the cure of varicose veins and haemorrhoids. Third, pyaemia occurring 
after parturition constitutes one of the most common and fatal forms 
of so-called " puerperal fever." Fourth, pyaemia not very unfrequently 
originates in acute suppurative inflammation taking place at the sur- 
face or in the substance of bones — cases in which, as a rule, the perios- 
teum becomes extensively detached, and the bone necrotic. Fifth, 
many varieties of so-called unhealthy inflammation, such as erysipelas, 



PYEMIA. 



255 



diffuse cellular inflammation, carbuncle, dissection-wounds, and malig- 
nant pustule are often fatal on account of the supervention of this 
complication. It may be added that when pyaemia manifests itself 
after injuries or operations, it is generally preceded by some obviously 
unhealthy condition of the implicated tissues; and also that pyaemia is 
far more liable to originate in affections of certain organs and tissues 
than in those of others. Among the former may be included the con- 
nective tissue generally, the bones, the pelvic organs both in the male 
and female, and the veins. That pyaemia is in a large number of cases 
imparted by contagion is quite beyond dispute. It is thus that it often 
spreads in the surgical wards of a hospital, and among the puerperal 
inmates of a lying-in institution. In all such cases there is good 
reason to believe that it is transmitted from patient to patient by direct 
inoculation at the raw surfaces of wounds or of the placental area ; or 
rather that, not so much pyaemia is transmitted directly from patient 
to patient, as some form of erysipelatous or other unhealthy inflamma- 
tion is thus transmitted, of which pyaemia is a common accident. It 
is certain, on the other hand, that even when it complicates the puer- 
peral state and surgical wounds, it often arises, so far as we can dis- 
cover, de novo, and altogether independently of specific influences. 
There can be little doubt that it is very frequently indeed, if not 
always, of idiopathic origin when it occurs without breach of surface. 
It still remains to consider whether there are any special conditions of 
system and any special conditions of a patient's surroundings which 
render him peculiarly liable to become pyaemic. In reference to this 
point it may be remarked that age and sex have no distinct influence; 
that patients apparently in the best of health are often struck down 
with pyaemia, and that indeed, when pyaemia pervades a ward, it by no 
means specially selects the weakly and the cachectic in preference to 
the robust and healthy-looking ; and, again, that pyaemia does not arise 
with special frequency in connection either with simple overcrowding, 
bad ventilation, or common filth. 

Morbid Anatomy and Pathology. — The post-mortem phenomena 
which characterize the presence of pyaemia are (as stated in our defini- 
tion of the disease) patches of congestion, haemorrhage, inflammation, 
suppuration or gangrene, disseminated more or less abundantly through- 
out the organs and tissues of the body. These are most common in 
the lungs, and often, indeed, confined to them. We find here, irregu- 
larly scattered but mostly abutting on the surface, circumscribed 
patches ranging from the size of a pea to that of a walnut. These are 
sometimes distinctly apoplectic, in which case they may be almost 
black or else decolorized in a greater or less degree, solid or broken 
down more or less extensively into a puriform pulp ; sometimes they 
present the ordinary characters of lobular pneumonia ; sometimes they 
are simple abscesses or gangrenous cavities. These different characters 
depend in part no doubt on the stage at which death has taken place, 
but are often due to individual peculiarities of different cases. There 
is usually more or less congestion and oedema of the general lung- 
tissue, and occasionally diffused pneumonic consolidation and more or 
less abundant secretion of mucus into the bronchial tubes. There is 



256 



SPECIFIC FEBRILE DISEASES. 



probably always a deposit of pleural lymph over and around each 
pysemic lump which involves the surface of the lung; and not mi fre- 
quently general pleurisy ensues. Subpleural petechia? are common. 
The surface of the heart, like that of the lungs, is often studded with 
small extravasations of blood ; as also are the substances of the cardiac 
walls, and the subendocardial tissue. And sometimes, generally in 
relation with these extravasations, small yellowish patches of disinte- 
grating tissue or abscesses may be discovered. When these reach 
either the inner or outer surface of the heart they are apt to provoke 
inflammation of that surface. Neither pericarditis nor endocarditis is 
of rare occurrence. Of the abdominal organs, the liver, spleen, and 
kidneys most frequently suffer. In the liver, generally in connection 
with patches of congestion or of anaemia, we sometimes find small buff- 
colored spots of disintegrated tissue, sometimes abscesses of consider- 
able size full of greenish purulent fluid. The morbid conditions pre- 
sented by the spleen and kidneys are almost exactly those which are 
met with in embolism or thrombosis of the vessels of these organs. 
In the spleen we observe apoplectic or fibrinous blocks of various sizes, 
which have often undergone more or less disintegration and softening, 
or even conversion into abscesses. The kidneys are sometimes studded 
(chiefly in the cortex) with small abscesses, grouped for the most part 
in lines perpendicular to the surface and surrounded by a halo of con- 
gestion. Occasionally no abscesses have formed, but almost the whole 
of their tissue is mapped out by tracts and bands of deep congestion, 
which alternate with and surround patches of which the color is un- 
naturally, pale. Spots of haemorrhage, patches of inflammation, or 
small abscesses may be present in any other of the abdominal organs, 
sometimes, for example, in the intestinal wall ; and the peritoneum 
may be affected exactly in the same way as the pleurae and pericardium. 
The brain is not very commonly the seat of pyemic changes: extrava- 
sations of blood are generally small in amount and limited to the sur- 
face; patches of softening exactly like those due to embolism, excepting 
that they rarely exceed the size of a horse-bean, may occur in any part 
of the organ ; abscesses containing greenish-yellow glairy pus attain a 
much larger size. Meningitis also occurs. The bones and joints are 
frequently involved. The secondarily affected bones become rapidly 
denuded of periosteum, and fetid pus accumulates upon their surface 
and probably in their substance, and rapid necrosis ensues. The syno- 
vial fringes of the joints get intensely congested, the synovia increased 
in quantity or replaced by pus or puriform fluid. The cavities of the 
joints become distended, and the parts around more or less inflamed. 
It is important to bear in mind that suppuration may occur in the 
neighborhood of joints without involving them, and that pyasraic in- 
flammation of joints is not always suppurative. It must be added to 
the foregoing account that secondary inflammations, suppurative or 
not, manifest themselves frequently in the connective tissue and among 
the muscles ; and that, of organs which have not been specially named, 
the eye, the prostate, and the testis are very apt to suffer. The skin 
never presents any characteristic change ; but it is often slightly jaun- 
diced, and occasionally presents petechia?; sudamina are common. 



PYEMIA. 



257 



The condition of the blood and bloodvessels in pyaemia is a matter 
of great interest. The bulk of the circulating fluid, and the vessels in 
the greater part of their extent, have usually the aspect of perfect 
health. The coagula, indeed, which are found post mortem in the 
heart and larger vessels usually differ in nothing from coagula found 
under other circumstances ; very rarely a few soft masses of disinte- 
grated fibrin or of corpuscles resembling pus may be found imbedded 
in them. But, with this exception, it is only in the arteries which lead 
to the secondary morbid patches, and in the veins which are involved 
in the primary lesion, that visible morbid phenomena are present. 
The minute arteries distributed to each patch of pulmonary disease are 
always found filled and obstructed either with ordinary thrombi or 
with a soft yellowish material, consisting of disintegrated fibrin and 
corpuscles, or in some cases of these mingled with what appear to be 
groups of pus-cells. Similar coagula have been detected in the small 
vessels leading to the diseased patches occurring in the heart, spleen, 
and kidneys, and doubtless are always present in the arteries which 
are connected with the generalized pysemic lesions. The veins which 
are involved in the primary inflammatory process are in a very large 
proportion of cases obviously diseased. It is true that they have in 
some cases, even after careful dissection, appeared to be entirely 
healthy. But when we bear in mind that in other cases the presence 
of diseased veins has only been detected after some hours of minute 
investigation, we shall see reason to suspect their existence in cases 
where they have been reported to be absent. When diseased, their 
parietes are thickened and indurated ; they may be entire, or may com- 
municate by orifices resulting from ulceration or some other cause with 
the morbific elements in which they are imbedded; and their interior 
is occupied by coagula. These are mostly adherent, and more or less 
decolorized ; they may be solid throughout, but more commonly are 
reduced in their interior into a reddish or yellowish puriform pulp or 
fluid. This fluid appears generally to consist of disintegrated fibrin 
only, but is in some cases true pus. It is mostly separated from the 
venous walls by a layer of fibrin, and is generally shut out from the 
proximal portion of the venous channel wherein it lies by a continua- 
tion of this layer of fibrin, which forms a kind of diaphragm or septum 
between them. In some cases no mechanical impediment whatever 
exists to prevent the free admixture of the pus contained in the vein 
with the general circulation. 

We are now in a position to discuss the proximate cause of pyaemia. 
It was formerly supposed that the secondary inflammatory patches were 
mere deposits of pus which had been absorbed as such by the veins 
and carried to the localities in which abscesses were found. But, un- 
fortunately for this view, pus as such is not found to circulate with the 
blood, and the secondary patches of disease are never in the first in- 
stance, and not often at any time, distinctly purulent. The theory of 
embolism, however, here comes to our aid. There is no doubt that the 
secondary foci of disease are almost exactly such as would be produced 
by embolism of the arteries leading to them ; and we find, in fact, 
that these arteries are really plugged. But we find, further, that these 

17 



258 



SPECIFIC FEBRILE DISEASES. 



plugs are identical in composition and appearance with the coagulated 
material, which blocks up the veins of the primarily inflamed region. 
It is reasonable, therefore, to assume that the diseased veins are really 
the sources of emboli, which becoming impacted in the pulmonary ar- 
teries, induce characteristic changes in the parts beyond, and that the 
phenomena of pyaemia are, therefore, in large measure due to the dis- 
semination in pellets of the morbid matters — pus, disintegrated clot, 
and the like — which these veins contain. In favor of this view are 
the facts that such pellets have been recognized in transitu, and that 
pyaemia is especially liable to occur where veins have been the subject 
of operation, and where inflammation attacks parts in which the veins 
are abundant and large, thin-walled, or incapable of collapsing — such 
parts, for example, as the contents of the pelvis, the uterus after partu- 
rition, the cancellous structure of bones, and the meninges of the brain. 
There can indeed be little doubt of the correctness of the above ex- 
planation, so far as it goes, and little doubt also that the quality of the 
emboli has a marked influence over the quality of the processes which 
they induce, and that hence whether these latter be gangrenous, sup- 
purative, or simply inflammatory, depends in no small degree on the 
special nature of the process going on in the primary seats of dis- 
ease. But will embolism alone explain all the phenomena of pyaemia? 
To this question Virchow replies in the negative. He considers pyae- 
mia to be a twofold disease, comprising, in the first place, phenomena 
due to embolism, and, in the second place, phenomena due to the ab- 
sorption of some more subtle poison. These latter, which he regards 
as the more important, have been collectively termed septiccemia, and 
he considers that these two groups of phenomena may occur independ- 
ently of one another. A very strong argument in favor of this view 
is the fact that patients occasionally die with all the ordinary symptoms 
of pyaemia, arising from some unhealthy wound, in whom no lesions 
whatever can be discovered post mortem. Such cases, which are very 
acute in their progress, are not unfrequently met with in the course of 
the endemic prevalence of pyaemia, and are regarded by many as cases 
in which death has supervened before the specific lesions have had time 
to develop themselves. The discovery of bacteria in the blood of pyae- 
mic patients is a matter of much interest. But their subsequent dis- 
covery in the blood of patients who are not pyaemic, and never become so, 
renders it highly improbable that they are the specific cause or contagium 
of septicaemia or pyaemia. So far, then, as our present knowledge goes, 
pyaemia seems to be due to the introduction into the circulating blood, 
through the medium of certain implicated veins, of showers, so to 
speak, of inflammatory products, these being partly solid, in part proba- 
bly fluid, and charged more or less distinctly with the special prop- 
erties of the local inflammation which gave them origin. The presence 
of these in the blood causes in the first instance, partly by embolism, 
partly by thrombosis, obstruction of the pulmonary arteries with certain 
characteristic lesions in the lungs, and at a later period obstruction of 
various of the systemic arterioles with similar characteristic lesions in 
the districts which they supply. It imparts also specific poisonous 
properties to the blood. It is easy to understand from this view how it 



PYAEMIA. 



259 



is that the lungs are, as a rule, affected both earlier and more exten- 
sively than any other organs. 

Symptoms and Progress. — The symptoms which usher in an attack 
of pysemia are generally well-marked, unless the condition of the pa- 
tient or the nature of the disease under which he is laboring at the time 
confuses them. The first symptom to attract attention is almost with- 
out exception a sudden, severe, and prolonged rigor, followed by pro- 
fuse perspiration. The patient may recover from this, and for a long 
time appear to be restored to health. But before long, it may be the next 
day, or at some earlier period, the rigor returns with its after sweating 
stage ; and again and again, at varying intervals, rigors and sweats 
recur. In the course of a day or two the conjunctivae and skin assume 
a sallow tinge ; the patient becomes dull and heavy, or it may be rest- 
less, and acquires very much the manner and aspect of a patient suffer- 
ing from some form of continued fever. In company with the above 
symptoms, or in succession to them, others of more or less importance 
show themselves. The pulse becomes rapid, weak, and perhaps in- 
termittent. The tongue becomes glazed and fissured, or coated, and 
after a time dry and brown, the lips parched, the teeth covered with 
sordes. > The patient is thirsty, loses his appetite, suffers often from 
nausea and vomiting, and not unfrequently from diarrhoea. The res- 
pirations become shallow and frequent, and the respiratory acts at- 
tended with dilatation of the nares or separation of the lips, and either 
a sniffing or a sipping or a sucking sound. Cough often supervenes, 
attended probably with pains in the chest, evidences of pleurisy or of 
consolidation of the lungs, and of excessive secretion into the bron- 
chial tubes. The skin, in the intervals between the perspirations and 
rigors, is often dry and harsh, and may present sudamina. The sallow- 
ness generally increases, and often amounts before death to well-marked 
jaundice. Pain and swelling in or around joints or in other parts of 
the connective tissue often present themselves, and pus may form 
rapidly in these situations. As the disease advances the patient be- 
comes excessively prostrate, his face shrunk and for the most part 
pale, his mental functions disturbed; slight delirium comes on, some- 
times coma, sometimes convulsions ; and death ensues usually in from 
four to ten days. Sometimes pyseniia takes a more chronic course : the 
symptoms are then altogether less strongly pronounced, the fever as- 
sumes the characters of hectic fever, abscesses form in the joints and 
other superficial parts, and the patient sinks from exhaustion at the end 
of a few weeks or even a few months, or in rare cases recovers after a 
protracted convalescence. 

We will consider some of the symptoms of pyaemia more in detail. 

The patient's aspect may at first be healthy-looking or nearly so, but 
soon becomes dull and oppressed. The face is sometimes flushed, 
sometimes pallid, and often these conditions alternate. Towards the 
close of the disease pallor generally becomes established, and the coun- 
tenance shrunken and anxious, or of that dull expressionless aspect 
which is common in the last stages of many febrile disorders. Rigors, 
though occasionally absent, constitute one of the most striking phe- 
nomena of pyaemia. They vary in number and frequency, sometimes 



260 



SPECIFIC FEBRILE DISEASES. 



recurring at short and irregular intervals, sometimes assuming a quo- 
tidian character, and generally ceasing after the first two or three days. 
Their duration ranges from a few minutes up to half an hour. The 
temperature of pyaemia has a good deal of resemblance to that of ague ; 
the rigors are always attended with a rapid rise, which is followed by 
an almost equally rapid fall. During or after the first rigor, the tem- 
perature may reach 104°, 105°, or even 107°, or more, and the sub- 
sequent fall carries it down probably to a little above the normal, oc- 
casionally even below it. Subsequently, according to circumstances, 
the temperature may present a succession of similar elevations and 
depressions, or maintain a nearly uniform level. Death may be pre- 
ceded either by a normal, a low, or even a very high temperature. 
The skin, which is often harsh and dry, perspires profusely after the 
rigors, and copious perspirations recur from time to time during the 
progress of the malady, and attend its last stage. 

The respiratory acts, as the disease advances, become frequent inde- 
pendently of the presence of pulmonary complication, and not uncom- 
monly attain a frequency of 40, 50, or 60 in the minute; and the 
breath is said to acquire a peculiar sweet odor. The pleuritic exuda- 
tion, the pulmonary lesions, and the excessive formation of bronchial 
mucus, may each or all aggravate the symptoms due to the respiratory 
organs ; and may induce dyspnoea, cough with various forms of ex- 
pectoration, pleuritic stitches, and friction, crepitation, rhonchus, or 
other auscultatory phenomena. 

The feebleness of the pyaemic pulse is remarkable. It is generally 
rapid from the beginning, or, if not rapid, variable, so that the slightest 
exertion of body or mind raises it 20, 30, or even 40 beats in the 
minute. As the disease advances, the pulse frequently rises to 140 or 
160 in the minute, and may even reach 200; it then tends to become 
irregular and almost imperceptible. It is possible that pericardial fric- 
tion or other signs of cardiac implication may be present. 

Abdominal pain and tenderness may be caused by the presence of 
hepatic or splenic congestion or inflammation, or of circumscribed peri- 
tonitis in connection therewith. The jaundice, which is so common 
in pyaemia, appears to be quite independent of the presence of pyaemic 
deposits and abscesses in the liver. Frerichs remarks that, " to all ap- 
pearance the jaundice is here the result of an impaired consumption 
of bile in the blood, arising from an abnormal condition of the meta- 
morphic processes which go on in that fluid." 

Urea is largely increased, and often the urine contains a small quan- 
tity of albumen. 

Arthritic and other superficial abscesses are far more common in 
the chronic than in the acute form of pyaemia. Their formation is 
mostly indicated by the usual symptoms which attend such inflam- 
mation. Sometimes, however, they come on rapidly and with little or 
no pain. 

The nervous symptoms are much like those which attend typhus and 
some other severe forms of specific fevers. They vary, but comprise 
in the first instance either restlessness or apathy and drowsiness, and 
later on delirium, which may be violent, but is generally muttering, 



PYJEMIA. 



261 



and often passes into coma. Muscular debility is always well-marked 
from the beginning, and soon becomes extreme. There are often 
tremors or subsultus, and sooner or later loss of control over the blad- 
der and rectum. 

The time at which pyaemia arises in relation to the morbid condition 
on which it supervenes varies. In accident and operation cases, and 
in those of carbuncle and pyaemia, it may probably come on at any 
moment from the commencement of suppuration up to the period of 
complete recovery. In cases of acute suppuration connected with bone, 
and acute necrosis, pyaemic symptoms are sometims present almost 
from the first. In puerperal cases pyaemia usually manifests itself be- 
tween the third and the tenth or twelfth day after labor. 

The prognosis of pyaemia is exceedingly unfavorable. There is little 
doubt that cases do occasionally get well ; at the same time it rarely 
happens that this event ensues in cases which, from the severity of 
their symptoms, are distinctly recognized as being pyaemic during life. 
The cases in which recovery usually takes place are those in which the 
symptoms from the beginning are mild, and which would probably not 
be recognized as pyaemic but for the fact of their occurrence during 
the endemic prevalence of the disease in the wards, say, of a lying-in 
hospital. 

There is not much difficulty generally in the diagnosis of pyaemia 
when it arises after surgical injuries or parturition. There is much 
more difficulty when it occurs in patients who are already prostrated 
by acute inflammatory affections, such as carbuncle or erysipelas, the 
symptoms due to which indeed are not unlike those of pyaemia itself. 
And it is particularly apt to be misunderstood when it arises out of 
some deepseated suppuration. The diseases for which it may be 
especially mistaken, and for which it has been mistaken over and over 
again, are typhus and enteric fevers, internal acute inflammations 
(especially of the lungs), urethral and bladder affections in which the 
kidneys have become involved, glanders and acute rheumatism. It 
may be added that it is a good rule, when a case comes under treat- 
ment in which typhoid symptoms with great prostration have developed 
themselves very rapidly, and in which from the absence of any specific 
symptom the physician hesitates to form a definite diagnosis, to ex- 
amine the limbs and surface of the body carefully. It has more than 
once happened to the writer in such cases to recognize, by the increased 
bulk of a thigh or arm, the source of the symptoms in the existence of 
a subperiosteal abscess. 

Treatment. — Very little, unfortunately, can be done medically for a 
case of pyaemia. We cannot cure the complaint; we cannot arrest it; 
we cannot, so far as we know, eliminate from the system any poisonous 
matter to which it may be supposed to be due. Quinine has been ex- 
hibited with the object both of checking the periodic rigors, and re- 
ducing excessive temperature ; cold baths also have been used with the 
latter object; hot baths have been employed to promote perspiration, 
purgatives to aid elimination from the bowels, antiseptics of various 
kinds to obviate the supposed putrefactive tendency of the disease. 
But all to little purpose. Our main aim must be, on the one hand, to 



262 



SPECIFIC FEBRILE DISEASES. 



support the patient's strength by regulated and suitable diet and the 
moderate employment of stimulants, in aid of which vegetable tonics 
in combination with the mineral acids are often useful ; on the other 
hand, to relieve, as far as may be, all distressing symptoms and inju- 
rious complications, for which various purposes no drug is so generally 
useful as opium or morphia. It should be added that, where symp- 
toms suggestive of pyaemia show themselves, it is of the utmost impor- 
tance to attend to the condition of the part which is its supposed 
source ; not so much, however, for the purpose of arresting pyaemia in 
actual progress as of preventing the occurrence of what may perhaps 
only threaten. Unhealthy wounds should be freely laid open, deep- 
seated abscesses freely incised, and, if deemed necessary, antiseptic or 
caustic injections or applications freely employed. 

In surgical and obstetrical practice, especially that of hospitals, the 
question of the prevention of the spread of pyaemia is one of the 
highest interest. JSTo doubt pyaemia occurs very frequently sponta- 
neously among both surgical and obstetrical patients. But, whenever 
either pyaemia or erysipelas, no matter how it has originated, appears 
among groups of such patients, we know that there is a remarkable 
tendency for it to spread. To obviate this tendency, extreme cleanli- 
ness, ample ventilation, scrupulous nicety with respect to the treatment 
and dressing of raw surfaces, and especially the utmost care not to 
allow infection to be conveyed from one to another by the fingers of 
the medical and other attendants, are essential. 



LEPROSY. (Elephantiasis Grcecorum.) 

Definition. — A specific disease, endemic in many parts of the world, 
characterized by the slow development of nodular growths in connec- 
tion with the skin, mucous membranes, and nerves, and (in the latter 
case) by the supervention of anaesthesia, paralysis, and a tendency to 
ulcerative destruction and gangrene. 

Causation and History. — Leprosy is a disease which has been 
doubtless largely confounded with other maladies, such as elephantiasis 
Arabum, syphilis, and various affections of the skin, but has yet been 
recognized from the earliest times, has been described under various 
names, and has been regarded with perhaps more general superstitious 
awe and dread than probably any other known disease. It was 
probably not uncommon throughout Europe during the first two- 
thirds of the Christian era ; but there is no doubt that it underwent a 
marvellous increase during the twelfth and thirteenth centuries. An 
epidemic wave seems then to have spread slowly from the southeast to 
the northwest ; and it was assumed, indeed (though probably errone- 
ously), that at that time it was imported into Europe by the returning 
Crusaders. The disease prevailed generally with great severity dur- 
ing the succeeding two or three hundred years, then began to subside, 
and had finally disappeared from the greater part of Europe by the 



LEPROSY. 



263 



end of the seventeeDth century. This subsidence of leprosy was 
closely related in time with the asserted introduction of syphilis; and 
hence it has been maintained (in spite of the clearest proof to the con- 
trary) that these diseases are co-related, and their manifestations were 
modified results of the operation of the same virus. But although the 
greater part of Europe became thus free at the date above assigned, 
the disease lingered in the Faroe Isles up to the commencement of the 
present century, and still prevails in certain parts of Italy, Greece, 
Spain, Portugal, and Russia, and with especial severity in Norway, 
Sweden, and Finland. At the present day, however, leprosy is mainly 
a disease of tropical and subtropical climates, and among these its 
chosen habitats are, perhaps Central and Southern Africa, India and 
China, the West Indies, and South America. The aetiology of leprosy 
has been largely discussed. Temperature, climate, soil, race, habits, 
food, have all been regarded as predisposing, if not exciting, causes. 
That temperature has no obvious specific influence is manifest from the 
fact that the disease prevails alike in Norway and in India. That soil 
and climate are equally inoperative is shown by the fact that it occurs 
both on marshy soils and at high elevations, both on the seacoast and 
in inland regions, both in continents and in islands, and in nearly all 
latitudes. At the same time it is worthy of note that a large number 
of the localities which it specially affects are low-lying and marshy, 
and on the seacoast or on the banks of rivers. That race and habits 
are not specific causes is clear from the prevalence of the disease 
amongst races of the most diverse kinds, and amongst persons of the 
most opposite habits. Yet it may probably be admitted, and has been 
asserted, that of several races living associated together and under 
many similar conditions, some are more prone to leprosy than others, 
and also that the disease is on the whole more common among the poor 
and filthy than among the well-to-do and cleanly. As regards the in- 
fluence of diet, it may be pointed out that it has been attributed to the 
use of decomposing fish, but, unfortunately for this theory, the disease 
is met with where not only fish is never eaten, but where the diet is 
mainly vegetable. It follows necessarily that if the cause of leprosy 
reside in any of the conditions which have been enumerated, that 
condition has at all events as yet escaped recognition. Formerly the 
disease was regarded as highly contagious, and all communication be- 
tween the sick and the healthy was consequently rigorously interdicted. 
At the present day, however, its contagiousness is almost universally 
denied by scientific medical men ; and it is beyond doubt that the 
attendants on the sick apparently fail to take it, that children live 
habitually in the same house w 7 ith leprous members of their family 
without becoming affected, and that sexual cohabitation even may go 
on for years without the disease being transmitted from the diseased 
person to the healthy one. On the other hand, it seems to be clearly 
established that the disease is to a considerable extent hereditary — 
hereditary, that is to say, in the same sense as tubercle and carcinoma 
are hereditary, but not in the sense in which syphilis is hereditary. In 
other words, it appears, not that children are ever born with leprosy, 
but that the children of leprous parents are more likely to become 



264 



SPECIFIC FEBRILE DISEASES. 



affected than are the children of healthy parents — a fact which probably 
explains the supposed influence of race. It must indeed be admitted 
that the causes of leprosy, of its generally endemic character, and of its 
occasional epidemic prevalence, are alike unknown. That the disease 
has a specific character is quite clear ; and that the tendency to it (if 
not the disease itself) is transmissible from parent to child is equally 
clear. But whether it belongs to that class of diseases which is rep- 
resented by tubercle and carcinoma, or whether, like ague and goitre, 
it is the result of some obscure telluric condition, or whether, like 
scurvy and ergotism, it is due to some default or error of diet as yet 
unrecognized, or whether, like cholera, enteric fever, or syphilis, it is 
imparted in some special way by the sick to the healthy, are matters 
in regard to which we have no accurate knowledge. It may be added 
that certain recent statements in respect to the introduction of leprosy 
into the Sandwich Islands and into Australia, and its subsequent spread 
in those countries (assuming them to be correct), go far to establish its 
communicability. Dr. Liveing concludes that, if not contagious in 
the ordinary sense of the word, it is capable of propagation by the im- 
bibition of the excreta of lepers. 

Symptoms and Progress. — Leprosy is a disease of both sexes and 
all ages, but commences most commonly in early adult life. It is 
usually preceded by premonitory symptoms which continue for weeks, 
months, or even years, before the specific signs of the disease manifest 
themselves. These consist in the first instance in lassitude and depres- 
sion, attended with more or less febrile disturbance, rigors, nausea, 
and loss of appetite. After a time livid blotches make their appearance 
here and there on the surface of the skin, remain out for a few days 
or a few weeks, and then subside, to be followed at irregular intervals 
by other similar outbreaks. They are tender, elevated disks, or rings, 
or more or less irregular patches, varying perhaps from half an inch 
to two or three inches in diameter. In the course of time the blotches 
become more persistent, and their subsidence is followed either by 
brownish pigmentary stains, or by an unnatural whiteness and opacity 
of the skin, associated with more or less contraction and depression. 
The central area of a patch not unfrequently assumes one or other of 
these conditions, while its periphery is still extending in the form of an 
elevated livid ring. During the earlier of these stages the affection has 
often some resemblance to psoriasis, lupus, or acne rosacea, and is some- 
times termed macular leprosy ; during the later of them the condition 
of skin is sometimes designated morphoea nigra or alba, according as 
the cicatricial area is pigmented or colorless. 

The specific phenomena of leprosy now begin to develop themselves, 
and these vary according as the skin and mucous membranes on the 
one hand, or the nerves on the other, are principally affected. Many 
cases no doubt occur in which all of these tissues are implicated either 
simultaneously or in succession ; but in a large number the specific 
morbid processes are almost accurately limited to one or other tissue, 
and the disease hence assumes two distinct and easily recognized types. 
They are known as tubercular and anaesthetic leprosy respectively. 

In tubercular leprosy, Avhich is relatively most common in temperate 



LEPROSY. 



265 



climates, nodular elevations slowly develop themselves in the substance 
of the cutis, and mainly on the site of the macular eruption. These 
are attached by broad bases, become more and more prominent and 
sometimes pedunculated, and not unfrequently coalesce with one another 
so as to form irregular nodulated masses. They vary at length indi- 
vidually from perhaps the size of a hazelnut to that of a walnut. They 
are for the most part hard and resistant, of a dusky reddish or brownish 
hue, smooth and sometimes polished on the surface, and often, like 

| those of lupus, present a certain degree of translucency. They are 
attended with little inherent pain or uneasiness, but are more or less 

| tender, and are remarkable for their permanence and the little tendency 
which they manifest to undergo degeneration or ulceration. Neverthe- 
less they do occasionally, after a long time, become the seat of some 
partial fatty change, grow softer and almost fluctuating, and acquire a 
dirty yellowish hue; and not unfrequently also, when irritated by ex- 
posure, filth or injury, they become excoriated or ulcerated, or covered 
with a thin scab, and exude a serous or ichorous fluid. The growth of 
the tumors is attended with atrophy of the cutaneous glands and of the 
hair. The latter first becomes thin and dry and loses its color, and 
then disappears entirely. It is important, however, to note that the 
loss of hair is not, as in syphilis, general, but simply limited to the 
situations in which there is obvious disease. The tubercles of leprosy 
occur mainly on those surfaces which are most exposed to the air, 
namely, the face, hands, and feet, but they are common also on the 
extensor aspects of the limbs. On the face they chiefly affect the eye- 
brows and eyelids, the nose and lips, and the lobes of the ears. The 
nodulated thickening of the eyebrows and adjacent parts of the forehead 
gives a peculiar morose character to the expression, and the thickening 
of the nose and lips with the associated bronzing of the parts imparts 
to the European the appearance of the mulatto. When the face is 
thus affected the term leontiasis is sometimes applied to the disease. In 
the hands and feet the back or dorsum is chiefly involved. In addition 
to the cutaneous growths which have just been described, nodules of 
the same kind appear in the subcutaneous tissue. The morbid process 
is limited to the skin and subjacent tissues for a longer or shorter time ; 
but at length certain of the mucous membranes become implicated, 
especially those of the nose, mouth, and larynx. The affection here is 
of the same kind as that in the skin ; it consists in the formation of 
nodules which increase in size, run together, and sometimes form 
flattened elevations. The growths, however, are softer, more readily 
ulcerate, and on healing produce deep and dense cicatrices. In the 
progress of the disease the cartilages of the nose become not unfre- 
quently exposed, the tongue large, nodulated, and seamed with cica- 
trices, and the different parts of the larynx thickened and stiff, and its 
channel contracted. In association with the affection of the larynx a 
peculiar cough and hoarseness of voice become developed, which are 
very characteristic of the disease. According to Danielssen and Boeck 
the trachea and bronchial tubes may undergo the same changes as the 
larynx. The conjunctivas are apt to be similarly affected, and inflam- 
mation, suppuration, and perforation of the corneas to ensue. 



286 



SPECIFIC FEBRILE DISEASES. 



In anaesthetic leprosy, which is specially common in hot climates, it 
not unfrequently happens that no tubercles are ever developed. And 
the cutaneous affection may either be that which has been described as 
among the prodromal phenomena of leprosy, or it may be so slight that 
attention is first called to it by some impairment or change of sensi- 
bility. There may even be no structural change whatever. We will 
first consider the nervous phenomena, and afterwards the local pro- 
cesses going on in the skin and subjacent parts. In the first instance 
there may be a combination of hyperesthesia and anaesthesia, some 
parts being numb or insensible while others burn or tingle and are 
excessively tender, and not unfrequently area? of numbness are sur- 
rounded by rings of increased sensibility ; these conditions, moreover, 
replace one another, so that parts which were hyperaesthetic become 
anaesthetic ; and, further, they may occupy numerous scattered spots 
or pervade separately or in combination extensive tracts of skin. They 
are often connected, though by no means necessarily so, with the cutane- 
ous maculae. The affection of the sensory nerves is generally associated 
with affection of the motor nerves, and indeed the latter (although it 
seems to come on later) occasionally preponderates. Thus, there are 
often tremblings and jerkings of the limbs; but especially there soon 
supervene muscular paralysis and wasting. These latter conditions are 
most obvious in the hands and forearms, and in the corresponding parts 
of the lower extremities. The anaesthetic and paralyzed regions gradu- 
ally shrink, the fat, the muscles, and even the bones waste, and the 
skin contracts over them, becoming white or pigmented, and assuming 
more or less of a cicatricial character. Bullae not unfrequently form 
and burst, sometimes healing quickly and well, at other times leading 
to obstinate ulcers, which leave hard depressed cicatrices behind. After 
a time gangrene is apt to occur in the affected parts, more especially in 
the hands and feet. This sometimes begins from the surface, and 
gradually deepens, until the bones are exposed; sometimes begins 
among the deeper tissues, and involves the skin secondarily. It often 
ends in the separation of the bones, in the loss of fingers or toes, or 
even of a hand or foot. It is remarkable, however, how rapidly and 
perfectly wounds thus made heal up. 

The duration of leprosy is very uncertain ; that of the anaesthetic 
variety is, on the average, sixteen or seventeen years, that of the tuber- 
culated form eight or nine. Death is due partly to gradual impair- 
ment of nutrition, but mainly to the supervention of complications, 
especially phthisis, dysentery, and kidney affections. 

Morbid Anatomy and Pathology. — The morbid process on which the 
chief phenomena of leprosy depend consists in the infiltration of the 
affected tissues with innumerable small cells containing comparatively 
large nuclei. These, in accordance with Virchow's views, are proba- 
bly due to proliferation of the connective-tissue corpuscles ; and col- 
lectively form more or less extensive masses of new growth, which are 
almost identical microscopically with granulation-tissue and with the 
tissue of syphilitic gummata, or of lupus. The leprous growth differs, 
however, from the latter two especially, by its permanence and com- 
paratively little tendency to undergo degenerative changes. The new 



LEPROSY. 



267 



growths present, at all events during their earlier progress, a grayish, 
yellowish or brownish tint, are firm, translucent, and homogeneous in 
texture, and contain scanty bloodvessels and little blood. 

In tubercular leprosy the tumors commence in the skin around the 
hair-follicles and glands, which in their progress they gradually com- 
press and destroy, together with the majority of the other textures 
which they involve; the epidermis, however, remains for the most part 
normal, and the muscles of the hairs, in the beginning at all events, 
become hypertrophied. The tubercles do not usually admit of being 
enucleated, but are connected by processes with the subcutaneous con- 
nective tissue. Their formation beneath the skin and in connection 
with the mucous membranes essentially accords with the above descrip- 
tion. It must be added that both in the macular stage and in the 
anaesthetic form, the cutis, however slightly it may appear to be affected, 
is still the seat of specific proliferation. 

In anaesthetic leprosy the nerves are always implicated to a greater 
or less extent — the smaller branches being mainly involved, and of the 
nerve-trunks those portions which are most superficial and most obnox- 
ious to injury. They swell to several times their normal bulk, some- 
times uniformly, but more frequently irregularly, so as to present some- 
thing of a beaded character. They become at the same time firm, 
grayish, and translucent. The change is due to a proliferation of the 
cells of the connective tissue of the nerve-bundles (mainly of that which 
separates the individual nerves from one another, and of that which 
bounds and isolates their different strands), and exactly resembles what 
occurs in the skin and mucous membranes. At first the essential ele- 
ments of the nerves suffer but little from the adventitious growth which 
surrounds them; eventually, however, they undergo degeneration. 

We have already adverted to the statement of Danielssen and Boeck 
that leprous patients are liable to the development of specific tubercles 
throughout the bronchial tubes; they describe them also as occurring in 
the substance of the lungs, liver, and other organs. These statements 
have not, however, been fully verified by subsequent observers. It is 
certain, however, that in all forms of leprosy the lymphatic glands 
become largely hypertrophied, and mainly those which are in imme- 
diate connection with diseased districts — the glands which chiefly suffer 
being those of the groin and those of the neck and submaxillary regions. 
Distinct leprous infiltration and degeneration of the testicles is recorded 
by Virchow. 

The ulceration, gangrene, and other inflammatory processes, which are 
so common in the course of leprosy, seem to be due, not so much to any 
special tendency which leprous formations have to pass into such con- 
ditions, as to what may be regarded as accidental circumstances. Thus, 
in the case of tubercular leprosy, ulceration seems to result from the 
effects of exposure, cold, dirt, and other sources of irritation; and, in 
the case of anaesthetic leprosy, the ulceration and gangrene are probably 
mainly dependent on the irritative implication of the nerves. 

Treatment. — By common consent leprosy is an incurable disease; 
nor does it admit of alleviation or arrest by medicinal treatment; but it 
is doubtless well, when the case admits of it, to remove the patient from 



268 



SPECIFIC FEBRILE DISEASES. 



a locality in which the disease is endemic, to protect his surface as far 
as possible from injurious influences of all kinds, and to maintain his 
strength by appropriate food and various tonic adjuvants. 



AGUE. [Intermittent and Remittent Fever.) 

Definition. — A specific non-contagious fever, produced by malaria; 
characterized by enlargement of the spleen and by recurring attacks of 
fever attended each with a cold, a hot, and a sweating stage; having an 
indefinite duration, and a tendency to recur which may last for many 
years or during the whole of life. 

Causation and History. — Ague is undoubtedly not contagious. It is 
not communicable from man to man, nor does it spread from a centre, 
successively invading town after town and country after country. It is 
strictly an endemic affection, belonging to certain districts and induced 
in them by some poisonous influence which pervades them. Ague 
districts are scattered more or less irregularly over the whole non- 
aqueous surface of the globe, excepting apparently that of the frigid zone. 
And it may be added that the virulence of the poison which they yield 
increases for the most part as they approach the equator. They gener- 
ally present certain common features : they are tracts of low-lying 
marshy ground, often situated upon rivers or lakes or in the vicinity 
of the sea, often presenting a luxuriant vegetation, and always a porous 
soil, which is commonly to a large extent composed of decaying vege- 
table matter. But, however fever-stricken such places may be, the 
malaria which they breed is evolved at certain seasons only ; in our 
own country, and probably in all temperate climates, the dangerous 
periods are spring and autumn, especially autumn; in the tropics, the 
season of heat and drought which follows upon the periodical rains; 
and in all cases, it would seem that the poison is alone produced, or 
produced with special intensity, not when the marshy ground is 
thoroughly soaked, but when, after it has been thus soaked the sur- 
face to a little depth has undergone a rapid process of drying. What, 
it may be asked, is the condition common to all the variously situated 
aguish regions which causes ague? Is it high temperature? Clearly 
not; for many of the hottest regions of the earth are completely blame- 
less. Is it the presence of water? The answer must be No; for, if 
aqueous vapor could cause ague, all who frequent the sea, or live in the 
vicinity of rivers, should contract ague; and especially, aguish districts 
should be most dangerous at those very times when they are now most 
free. Is it the presence of decaying vegetable matter? Again the 
answer must be No. Decaying vegetable matter exists abundantly in 
places where ague never occurs ; and moreover, as Sir Thomas Watson 
remarks, if such matter could cause ague, Londoners ought at least to 
be occasionally infected by the contents of their dust-bins and by the 
neighborhood of Covent Garden market. But the specific influence of 
decaying vegetables in the causation of ague is disproved by the fact 



AGUE. 



269 



that ague prevails in certain places where no such matter exists. "In 
August, 1794, after a very hot and dry summer, our army in Holland 
encamped at Rosendaal and Oosterhout. The soil in both places was 
a level plain of sand, with a perfectly dry surface, where no vegeta- 
tion existed, or could exist, save stunted heath plants. It was uni- 
versally percolated to within a few inches of the surface with water, 
which, so far from being putrid, was perfectly potable. Here fevers of 
the intermittent and remittent type appeared among the troops in great 
abundance." (Watson.) Again, the soil of Hong Kong consists of 
disintegrated granite, containing, according to Dr. Parkes, less than 2 
per cent, of organic matter; yet ague, which had not previously pre- 
vailed, became rife and fatal at a time when the soil was being exten- 
sively excavated for building purposes. The last quotation illustrates 
another point of considerable importance in relation to the causation of 
ague, namely, the influence in this respect of upturning of the soil, of 
soil at any rate which has been long untouched. The malarious affec- 
tions which prevailed in the armies before Sebastopol are referred by 
Trousseau to this cause; and he also points out that in Paris, where ague 
is almost unknown, epidemics of limited duration have on several occa- 
sions been distinctly traced to the formation of extensive excavations. 

It would seem, therefore, that neither heat, nor water, nor decom- 
posing organic matter is alone capable of evolving the malarious poison; 
but that for its production there must be a certain porous character of 
soil, a certain degree of saturation of this soil with water — the surface 
having recently undergone desiccation — and a certain elevation of tem- 
perature. It may be added that nothing is more certain than that 
aguish districts may be rendered perfectly healthy by thorough drain- 
age. In London, most of which is built on land which was formerly 
marshy, and where ague was once largely prevalent, the disease is now 
rarely if ever met with unless it be imported. 

The malarious poison appears to be manufactured in the soil of the 
malarious district, and to be exhaled from the surface in company with 
the moisture which rises from it, and at night-time far more abundantly 
than in the day. It forms over the infective area a kind of invisible 
mist, which is denser and more potent in proportion to its proximity 
to the ground, and which extends to no great height above it. Indeed, 
it is well known that the ground-floors of houses in aguish districts are 
more dangerous to sleep in than are the higher stories ; and that the 
miasm rarely ascends to any great height the sides of mountains which 
adjoin such districts. Dr. Parkes considers that the upward limit in 
temperate climates is 500 feet, in tropical climates from 1000 to 1500 
feet. As might be supposed, the miasm may be carried by the wind 
and atmospheric currents beyond the limits of the area in which it is 
produced ; and thus, under certain circumstances, places which are 
miles away, and in all other respects healthy, not unfrequently become 
infected. It is important, however, to note that the miasm appears to 
be absorbed in its passage across water, so that the intervention of a 
river three-quarters of a mile or a mile broad, or of a similar breadth 
of sea, seems to give perfect safety. Even a belt of trees, acting prob- 
ably as a kind of filter, will often form an efficient barrier. For this 



270 



SPECIFIC FEBRILE DISEASES. 



latter reason it is especially dangerous to sleep under trees in malarious 
places. It is also dangerous (according to some) to drink the water, 
however pure it may seem to be, which is furnished by the soil of such 
localities. 

What, then, is this miasm? Is it a gas, is it some decomposing 
organic substance, is it a living thing? No direct proof has yet been 
adduced of the truth of either of these alternatives. There is, however, 
much, both in the behavior of the miasm and in its effects on the hu- 
man body, to indicate a generic relationship with the contagia of infec- 
tious fevers, and to render it probable therefore that the last of the 
alternatives above expressed is entitled to acceptance. Dr. Salisbury, 
of Cleveland, indeed, believes that he has discovered the specific cause 
in the sporules of certain algse, species of palmellse. 

There are certain facts in reference to the causation of ague besides 
those which have been already considered to which attention should be 
drawn. It seems to be well ascertained that the denizens of malarious 
districts tend to become, in a greater or less degree, acclimatized, and 
hence that they less readily contract ague than persons newly arrived. 
It is remarkable how little the negroes suffer in districts which are 
fatal to Europeans. Another well-ascertained fact is that persons suf- 
fering from fatigue or privation are much more liable to take the dis- 
ease than those who are well-fed, strong, and in robust health. Again, 
contrary to all we know of most other fevers, especially of the exan- 
themata, one attack of ague, so far from being protective, renders its 
subject more than ever liable to be attacked with it on exposure to its 
exciting cause. 

Symptoms and Progress. — The period of latency of miasmatic affec- 
tions varies within wide limits. Authentic cases are recorded in which 
persons who have been exposed to the paludal poison have manifested 
the first symptoms of fever within the ensuing four-and-twenty hours. 
On the other hand, it by no means unfrequently happens that persons 
who have been residing in aguish districts at the time of year when ague 
chiefly prevails have their first attack of ague many months after they 
have removed thence to some perfectly salubrious locality. Thus we 
frequently meet with persons, residing in healthy parts of London, who 
are attacked during the spring or summer with symptoms of ague, the 
poison of which was taken into the system during the previous autumn 
in Essex or in Kent, and had lain dormant during the whole of the 
intermediate period. 

Ague presents itself clinically in two well-marked extreme forms, 
which, however, pass one into the other by insensible gradations. The 
first of these is the intermittent fever, which is especially common in 
temperate climates, and comparatively mild ; the second is the remit- 
tent fever, which occurs chiefly in the tropics, and is of great severity 
and danger. We will first describe the phenomena of intermittent and 
then those of remittent fever. 

1. Intermittent fever is characterized by the occurrence of febrile 
attacks of some hours' duration, separated from one another by periods 
of apparently or at all events comparatively good health. The patient 
is attacked suddenly, or after having complained for some indefinite 



AGUE. 



271 



period of lassitude, headache, and general malaise, with a sense of chilli- 
ness, weariness, headache, muscular pains, and epigastric discomfort. 

The chilliness rapidly increases until the patient feels and looks as 
if he were suffering from intense cold. He begins to shiver, the sen- 
sation of shivering commencing in the back and extending thence to 
the rest of the body. The shivering is speedily converted into a severe 
rigor, attended with violent chattering of the teeth and convulsive 
tremblings of the trunk and limbs. At the same time the skin is dry, 
and assumes the papular condition known as " goose's skin the face 
and the hands and feet acquire a dusky hue, the face looking also 
pinched, the latter shrunken and wrinkled. Whilst this condition 
lasts the pulse is small, frequent, and often irregular, the respirations 
quick and sighing ; there is loss of appetite, thirst, and epigastric op- 
pression, not unfrequently associated with sickness ; the tongue is 
bluish perhaps, and slightly furred ; headache and pains in the back 
and limbs are often present, and sometimes torpor or drowsiness ; and 
the urine is pale, abundant, and passed frequently. The duration of 
this, which is termed the cold stage, presents great variety. In some 
cases it is represented by a slight sensation of chilliness of a few min- 
utes' duration only. It more commonly lasts from half an hour to 
one or two hours, and is occasionally prolonged to three or four hours, 
or even more. During the whole of the so-called cold stage the tem- 
perature of the patient is above the normal, and rises rapidly. The 
elevation of temperature begins in fact before the patient himself recog- 
nizes the commencement of his attack, and rises quickly and uniformly 
until towards the close of the stage ; at which time, even though he be 
still trembling violently with the feeling of intense cold, the ther- 
mometer placed in his axilla probably marks 105°, 106°, or even 
106.3°. 

After a time the cold stage begins to subside, and the next (the hot 
stage) commences. The rigors and aspect of chilliness gradually dis- 
appear — slight flushes at first alternating with the diminishing rigors, 
and then by degrees replacing them. The patient begins to feel com- 
fortably warm, and the shrunken and livid surface assumes the smooth- 
ness and hue of health. But gradually the feeling of heat becomes 
intense ; the patient looks excited and flushed ; the skin feels dry, 
harsh, and pungently hot ; the pulse becomes fuller, stronger, and soft, 
but maintains its frequency ; the respirations get more rapid and 
deeper, and the thirst more intense ; anorexia continues ; the urine is 
still abundant, but of a darker color and higher specific gravity ; and 
the headache, which differs in character from that previously com- 
plained of, becomes intense; mental confusion is not uncommon, and 
occasionally there is slight delirium. During this stage the tempera- 
ture continues high ; sometimes during the early part attains a higher 
elevation than was reached during the cold stage, sometimes, on the 
other hand, falls somewhat below it. The hot stage lasts from one or 
two hours up to four or five, but is occasionally prolonged to eight or 
ten hours. 

The hot stage is succeeded by the third, or sweating stage. The 
approach of this is indicated by the supervention of a general feeling 



272 



SPECIFIC FEBRILE DISEASES. 



of comparative comfort; the intense heat of skin diminishes somewhat, 
and moisture appears on the face and rapidly extends over the 
whole surface ; soon the patient is bathed in profuse sweats ; the tem- 
perature rapidly falls ; the pulse becomes less frequent and softer ; the 
respirations resume their normal rate ; the headache disappears ; the 
loss of appetite and the thirst abate ; the urine becomes scanty, but of 
variable color, depositing a sediment on cooling; and not unfrequently 
the patient falls into a gentle sleep. The duration of this stage is very 
variable, but is generally shorter than either of the other two. On 
emerging from it, the patient may be languid and listless, but for the 
most part appears to be restored to more or less perfect health. 

The duration of the febrile paroxysms and that of their different 
stages present considerable variety. The whole paroxysm may be 
completed in an hour or two, or may be prolonged to eight or ten, or 
even twelve hours. The cold stage, as has been pointed out, may last 
from a few minutes to some hours, and not unfrequently the shorter 
cold stage is followed by the longer and more intense hot stage. Again, 
the hot stage, which is often of some hours' duration, is occasionally 
absent — the sweating stage in such cases following immediately upon 
the cold stage. And, lastly, the sweating stage may be so slight as 
almost to escape recognition, or may be protracted for many hours. 

The period which intervenes between the cessation of one attack and 
the commencement of the attack next following is called the intermis- 
sion. In it the patient seems not unfrequently to be in the best of 
health. Sometimes, however, he suffers from more or less malaise, the 
degree and character of which depend on various circumstances which 
need not be specially considered. 

The period which elapses between the commencement of one attack 
and that of the attack which is next in sequence is termed the interval. 
And it is mainly in accordance with the length of this interval that we 
determine the different varieties of ague. In one variety the interval 
is twenty-four hours, or thereabouts, and there is consequently a daily 
febrile paroxysm. This is termed quotidian ague. In another variety 
the interval is forty-eight hours, more or less, and the paroxysm occurs 
every other day. This should strictly be called secundan ague, but 
those who framed its name chose to reckon the day of the first attack 
as one day, the day of freedom as another day, and the day of the next 
attack as the third day, and consequently attached to it the inaccurate 
but now well-known name of tertian ague. In another variety the 
febrile paroxysms occur every third day, and this, which should 
strictly be named tertian ague, has received the designation of quartan 
ague. In addition to these three principal varieties, others which are 
much rarer are occasionally met with. Thus in some cases the fits 
occur every fourth, or fifth, or even sixth day. And in some cases we 
have what are termed double tertians or double quartans. In the 
double tertian the patient has febrile paroxysms occurring every day, 
but, while those of the odd days correspond with one another, in time 
of commencement, in duration, and probably also in some other fea- 
tures, those of the even days, though presenting a like agreement among 
themselves, differ markedly from those of the other series. In the I 



AGUE. 



273 



double quartan the patient suffers as it were from two series of quartan 
attacks, the first series of similar paroxysms occurring, say, on the first, 
fourth, and seventh days, the second series occurring on the second, 
fifth, and eighth days. 

In quotidian ague the febrile paroxysm usually commences earlier, 
and lasts longer, than in either of the other common varieties, often 
persisting for ten or twelve hours. In the tertian variety its duration 
is usually six or eight hours, in the quartan, four or six. On the other 
hand the cold stage is shortest in quotidian, longest in quartan ague. 
The interval, as has been pointed out, is rarely exactly twenty-four, 
forty-eight, or seventy-two hours ; when it falls short of either of these 
periods, each successive febrile attack commences earlier in the day 
than that which immediately preceded it, and is said to anticipate; 
when the interval is prolonged, the periodical paroxysms become later 
and later, and are said to postpone. In the former case the disease is 
generally becoming more severe, in the latter case there is usually a 
tendency towards improvement. Tertian ague is (in Europe, at any 
rate) more common than either of the other varieties. None of them, 
however, is rare, and they readily and not unfrequently pass the one 
into the other. 

2. Remittent Fever — the form of ague most common in tropical cli- 
mates — is much more serious and dangerous to life than the intermit- 
tent forms of ague which have just been considered. Its distinguish- 
ing feature is, that the febrile paroxysms, which come on once or twice 
a day, are hot separated from one another by intermissions of complete 
apyrexia, but are rather to be regarded as exacerbations of an abiding 
febrile state. It may be added that the cold stage of each exacerba- 
tion is always of short duration, sometimes indicated by a few minutes 
only of shivering or sense of chilliness, and sometimes escaping recog- 
nition ; that the hot stage is much prolonged, lasting from six to twelve 
hours; and that the sweating stage is imperfectly developed, and merges 
into the period of remission, from which it is undistinguishable. The 
attack of remittent fever is sometimes sudden, but is more commonly 
preceded by premonitory symptoms, such as chilliness, lassitude, loss 
of appetite, nausea, epigastric uneasiness, and pains in the head and 
limbs. The actual febrile paroxysm begins with a rigor or slight chil- 
liness, to which the hot stage speedily succeeds, and after some hours 
ends in perspiration and the period of remission — the remission, like 
the hot stage, varying in length from two or three to twelve hours. 
The paroxysms usually increase in intensity day by day for a few days. 
The symptoms which the patient presents are for the most part like 
those which attend intermittent fever, but some of them are much more 
severe. The temperature attains no greater height, but it never falls 
during the remissions to the normal standard; there is no difference as 
regards the respirations and pulse, except perhaps that the latter, with 
the progress of the disease, tends to become quicker and weaker. Sick- 
ness is much more severe during the hot stage of remittent fever than 
in the corresponding period of intermittent fever, is often very dis- 
tressing, and sometimes attended with hsematemesis (black vomit); the 
tongue is drier, and occasionally there is slight jaundice ; headache and 

18 



274 



SPECIFIC FEBRILE DISEASES. 



pains in the limbs are more intense ; confusion of intellect is more 
common, and drowsiness, delirium, and coma are not unfrequent. The 
patient often passes into a distinct typhoid condition, with dry, brown , 
tongue, sordes on teeth, muttering delirium, subsultus tendinum, and 
other symptoms of the kind. 

Remittent fever in its most typical forms presents at first sight an 
almost closer relationship, in the type of its fever, with enteric fever 
and hectic (which are also usually distinctly remittent), than with the 
varieties of intermittent fever. And, indeed, enteric fever and hectic 
were formerly, in many of their forms, termed remittent, and regarded 
as of malarious origin. It is certain, however, that the so-called remit- 
tent fevers of temperate climates have no affinity with ague. And, on 
the other hand, it is equally certain that there is no essential difference 
between the remittent and intermittent forms of ague,. for not only do 
they arise from the operation of the same miasm, and present symp- 
toms essentially alike, but their varieties shade into one another by in- 
sensible gradations, and they alternate with one another, or replace one 
another, in the same individual. 

The effects of the ague-poison are not always in accordance with the 
description which has been given above ; thus cases are described in 
which the paroxysm consists in a violent and prolonged cold stage only, 
during which the temperature is actually lowered — the patient suffer- 
ing from extreme anxiety and intense thirst, and looking like a corpse; 
others, in which the sweating comes on early, is exceedingly profuse 
and of long duration, and during which the temperature falls rapidly, 
and the patient lies in a condition of extreme collapse ; others, in which 
the patient passes into a state of coma or of delirium, or has epilepti- 
form or tetanoid convulsions coming on in the cold or hot stage, and 
continuing until the establishment of the sweating stage; others, in ! 
which haemorrhage takes place from the nose, stomach, bowels, blad- 
der, or into the substance of organs ; and, again, others in which, inde- 
pendently of any other peculiarity, he falls into a condition of ex- 
haustion, and lies torpid, motionless, and as if asleep, for many hours. 1 
Further, there are various neuroses which are distinctly forms of ague, 
the more important of them being neuralgic affections of one or other 
of the branches of the fifth pair. That involving the supraorbital 
constitutes one form of the malady known as "brow-ague." These | 
may be recognized as being malarious partly by their periodic charac- 
ter, partly by their occasional supervention on a more or less distinct 
cold stage, partly by their occurrence in a malarious district, partly by 
the fact that the patient has already been the subject of ague. 

There are one or two points in reference to the paroxysms of ague 
to which we have hitherto only very briefly alluded, but which are never- 
theless of considerable importance. In intermittent fever, during the 
cold and hot stages the urine is usually secreted in considerable abun- 
dance, is pale and of low specific gravity, and the patient generally 
has very frequent desire to miturate. He passes an excess of urea, uric 
acid, and chloride of sodium, while phosphoric acid is diminished. 
During the sweating stage the urine becomes scanty and darker colored, j 



AGUE. 275 

and the amount of the excreted solids which was previously in excess 
undergoes diminution. In the intermission urea and uric acid fall 
below the normal standard. In the remittent form of ague the same 
peculiarities exist, but are necessarily somewhat less obvious. In both 
forms there is occasionally albuminuria or hematuria, with renal casts. 
The spleen is invariably enlarged during the paroxysms, becomes espe- 
cially swollen during the cold stage, and may generally be easily recog- 
nized by palpation or percussion ; it then subsides, and during the 
intermission may return to its normal bulk. If, however, the ague 
persists, the splenic enlargement becomes more or less permanent. 

The duration of ague presents great varieties. An attack will prob- 
ably always subside (unless death supervenes) after some indeterminate 
period ; especially it will subside if the patient be removed from the 
district in which he contracted it. But this subsidence is rarely final. 
In the great majority of cases the patient remains for months or years, 
or for his lifetime, liable to fresh attacks of ague, even if he never 
again ventures into a malarious district. The attacks then recur at 
irregular intervals, and are generally determined by some accidental 
circumstance, such as over-fatigue, an attack of catarrh or indigestion, 
or the supervention of any mild ailment or serious disease. In other 
words, the malarious poison becomes a portion of his being, and seems 
to tinge and qualify any morbid condition which happens to supervene. 
Death from the ordinary intermittent fevers is very rare ; but remittent 
fever, unless it be promptly treated, is a very fatal disease. The pa- 
tient dies for the most part in the typhoid condition, and rarely (ac- 
cording to Dr. Maclean) before the eighth day. 

If ague assumes a chronic form, and especially if the patient has 
been long resident in an aguish climate, or has had periodical attacks 
for many years, organic changes take place in the liver and spleen ; 
their functions become impaired or perverted, and chronic conditions 
of disease sooner or later developed. Among the more important of 
these are various forms of cachexia and dropsy. In some cases the 
patients simply pass into a condition of debility and anaemia, on which 
general dropsy may supervene after a time ; in some cases jaundice 
becomes associated with this ansemia, and from the same affection of the 
liver as causes this, ascites or hsematemesis and melsena may eventually 
come on ; in some cases, again, degeneration of blood-corpuscles takes 
place in the spleen, and their conversion there into brown or black 
pigment-granules, and the diffusion of this pigment thence throughout 
the system, give a peculiar dirty or bronzed hue to the complexion. 
Some degree of such discoloration is, indeed, of common occurrence in 
persons who have had repeated attacks of ague. 

It may be added here that it is not uncommon for the denizens of 
malarious regions to become the subjects of the visceral lesions and 
cachexia which supervene on ague without ever having experienced a 
distinct attack of ague — the malarious poison appearing to affect the 
system slowly and insidiously, and without even the warning which an 
occasional febrile paroxysm might afford. 

Morbid Anatomy and Pathology. — The pathology of ague is very 
obscure ; and morbid anatomy throws little light upon it. We know 



276 



SPECIFIC FEBRILE DISEASES. 



that a poison (probably living) is taken into the system, and that this 
remains incorporated with it for an indefinite period, giving rise at 
irregular intervals to more or less distinctly periodical attacks of well- 
marked fever, attended with rapid destruction of tissue, high temper- 
ature, and congestion of internal organs, but more especially of the 
spleen. But where the poison lurks, why it acts periodically, and on 
what organ or organs it acts chiefly, are matters concerning which 
we do not positively know anything. There is, however, good reason 
to believe, on the one hand, that it is not discharged from any surface, 
and on the other that (whether it acts directly or indirectly thereon) its 
main effects are wrought through the agency of the sympathetic system 
of nerves. It is scarcely probable that the enlargement of the spleen 
and associated changes in the liver, important though they may be in 
many respects, are anything more than secondary phenomena. The 
only constant lesion discoverable after death is enlargement of the 
spleen. This organ becomes distended with blood, and often to many 
times its normal size; and if the patient die when the attack of ague 
is recent, it will be found large and congested. The liver, too, com- 
monly becomes to some extent engorged and increased in bulk. Con- 
gestion of the neighboring parts of the alimentary canal has also been 
observed; and it may be added that in hemorrhagic cases traces of 
hemorrhage at mucous surfaces and beneath the serous membranes may 
be discovered. 

Enlargement and induration of the spleen and liver are among the 
common results of long-continued or repeated attacks of ague, or of 
long residence in malarious districts. Another change to which these 
organs are liable is a peculiar dark or slaty discoloration, due to dis- 
integration of blood-corpuscles and their conversion into pigment- 
granules. In the liver this condition is referable to the changes which 
occur in minute extravasations of blood into the capsule of Glisson and 
the hepatic parenchyma; in the spleen, to similar changes going on in 
the blood which occupies the intermediate blood-passages. The pig- 
ment is apt- to escape from the spleen, to enter the general circulation, 
and to become arrested in the capillaries of different organs, more espe- 
cially the liver, brain, and kidneys, and thus not only causes them to 
be pigmented, but interferes more or less with their nutrition, and 
induces various organic changes and functional disturbances. 

Treatment — What the prophylactic treatment of ague should be 
may be surmised from the foregoing account of the disease. 1st, when 
practicable, malarious districts should be thoroughly drained and 
cleared of underwood or jungle; 2d, those who are compelled to remain 
in them should take ample precautions; should not go out in the 
evening, the night, or the early morning ; should sleep in the higher 
rooms of the houses they occupy ; should not drink the water of the 
locality unless it be well filtered or boiled ; especially should not expose 
themselves to the malarious influences when they are ill, or fatigued ; 
and on going out should, as Sir T. Watson suggests, wear charcoal 
respirators, and also regularly take such remedies as are efficacious in 
curing ague ; and, 3d, persons who are actually attacked with the dis- 
ease should be removed to some healthy locality. 



AGUE. 



277 



In treating ague medicinally we have to consider, first, the treat- 
ment of the paroxysms, and next that of the disease. It is reasonable 
to suppose that the ague-patient will experience some actual benefit 
if we assuage some of his discomforts, and hence that he will be 
benefited, during the cold stage by the application of warmth, either 
by packing, warm bottles, hot-air baths, or warm-water baths; during 
the hot stage by the maintenance of a cool atmosphere, by the use of 
light clothing, and by tepid or cold sponging; and, during both, by 
the administration of diluents. Little or nothing, in fact, is necessary 
beyond such simple measures. Other remedies, however, have been 
employed, and some reputedly with considerable success. Thus 
emetics have been sometimes given previous to the fit; and bleeding 
has been much lauded as a means of relief during the cold stage. The 
most valuable, however, of such special modes of treatment seems to 
be the exhibition of opium in largish doses (about thirty minims of the 
tincture) during the cold or hot stage. 

It is, however, of infinitely greater importance to attack the disease 
itself, and fortunately ague is one of those maladies for which we have 
almost unfailing remedies. Cinchona, indeed, its alkaloids, and arsenic 
are true specifics. There is no difference of opinion as to their efficacy ; 
the only difference which can exist is as to the mode of their adminis- 
tration and the dose. Of the several cinchona alkaloids, quinine, in 
the form of the sulphate, is undoubtedly the most efficacious, and it is 
certainly much more convenient of administration than cinchona itself. 
There are two principal modes in which quinine is administered; by 
some physicians it is given in single large doses some little time before 
the paroxysm is expected, by others in smaller doses at comparatively 
short intervals. According to the former mode from twenty to thirty 
grains of quinine may be given for a dose to an adult. The time of 
its administration here, however, becomes important. By some it is 
thought best to give it immediately previous to the expected paroxysm, 
by others immediately after a paroxysm and even during the sweating 
stage. The immediate object being prevention, it would certainly 
seem most reasonable that the quinine should be given so long before 
the expected occurrence of the paroxysm as to allow of its being fully 
absorbed into the system ; and hence, of the two specified alternatives, 
the latter should be preferred. The plan, indeed, of giving the larger 
dose during the sweating stage can scarcely be improved upon either 
in the case of remittent or quotidian ague. When, however, the par- 
oxysms are separated by longer intervals, it is probably best either to 
divide the large dose into two smaller doses and to give them at inter- 
vals, or to give the full dose between six and twelve hours previous to 
the expected attack. The other method, which is frequently pursued, 
is that of giving the quinine in smaller doses — three, four, or five 
grains — three or four times a day without reference to the times of the 
occurrence of the paroxysms ; and, indeed, it may be given freely even 
while a paroxysm is in progress. In some cases, owing to extreme 
irritability of the stomach, the quinine (in proportionately increased 
doses) must be given in the form of enema, or (in proportionately 
diminished doses) by subcutaneous injection. The time during which 



278 



DISEASES OF THE SKIN. 



the administration of the remedy should be persisted in must neces- 
sarily vary with the case. It should be given for at least a week or 
two after all symptoms have disappeared ; and should be at once re- 
newed if a tendency to recurrence manifests itself. It is important, 
however, to observe that quinine (and the same is true of arsenic) does 
not, by continuous use, even for many months, necessarily eradicate 
the disease. Arsenic is equally efficacious with quinine in the treat- 
ment of ague, and indeed sometimes effects a cure when quinine has 
failed. The liquor arsenicalis may be given in doses of from five to 
ten minims three or four times a day. 

It may be well to observe that it is generally considered advanta- 
geous to keep the bowels freely open, and that indeed, so at least it is 
asserted, quinine and arsenic seem occasionally to be quite inefficacious 
until a purgative has been administered; that the complications and 
sequelae of ague must be treated according to their nature; and that 
the diet (in regard to which no special rules need be laid down) must 
be regulated according to the condition, and the tastes or desires, of the 
patient. 



II.— DISEASES OF THE SKIN. 

INTEODUCTOEY EEMAEKS. 

Morbid conditions of the skin are of very great interest and impor- 
tance, partly because they are very common, partly because they are in 
many cases a very valuable aid to us in the determination of the nature 
of the internal maladies under which patients are laboring, partly be- 
cause their presence so largely affects, not only the health, but the com- 
fort and happiness, of those who suffer from them. Further, their 
position renders them comparatively easy of observation. For all these 
reasons they have been repeatedly examined and described with extreme 
care, and have been distinguished with a degree of minuteness and clas- 
sified with an amount of ingenuity which have been surpassed only in 
the distinction and classification of the members of the vegetable king- 
dom. The result has undoubtedly been largely to increase the range 
and exactness of our knowledge of skin diseases ; but it may be ques- 
tioned whether this result has not been to a considerable extent counter- 
acted by the confusion which the introduction of a large number of 
names to designate trivial and often fanciful varieties of disease, and 
the pains taken to discriminate between conditions which are essentially 
identical, have tended to create. 

There is, however, considerable excuse for minuteness of description 
and complexity of nomenclature of skin diseases, in the facts that the 
skin is an extremely complicated organism (comprising the epidermis, 
with the hair and nails, the papillary and reticular layers of the cutis 
vera, the subcutaneous connective tissue, and the sebaceous and sudo- 
riparous glands), any one or all of the constituents of which may become 



DEFINITION OF TERMS. 



279 



the seat of almost any of the various morbid processes which have been 
considered in a former section of this work ; that it varies greatly in 
character in different parts of the body, and is hence not equally liable 
everywhere to the same affections, or even to present identical appear- 
ances under the influence of the same disease; and, lastly, that it sub- 
serves various important functions (such as those of sensation, secre- 
tion, and excretion, and of protecting internal organs and structures), 
all of which are liable to modification or impairment in the presence 
of morbid processes. 

Classification and Definition of Terms. 

We shall not classify skin diseases either according to the special 
elements of the skin which are involved, as has been clone by Mr. Wil- 
son; or according to the visible peculiarities which the affections of the 
skin present, which constitutes the essence of Willan and Bateman's 
system; nor indeed shall we follow any strictly logical scheme of classi- 
fication. We shall, however, group them mainly in accordance with 
their mutual pathological affinities, but shall not hesitate to depart from 
this arrangement whenever it seems of practical utility, or convenient 
on any other grounds to do so. 

There are certain terms in common use in the description of skin 
diseases, which it will be convenient to enumerate and explain ; and the 
more especially as there will thus be afforded a suitable opportunity for 
indicating the principles of Willan's artificial, but nevertheless very 
simple and useful, classification. 

1. Macula. — By this term is generally meant a spot or patch of dis- 
coloration which does not fade on pressure, and in which, therefore, 
there is some obvious and more or less persistent deposit or change of 
texture. Freckles, moles, and port-wine marks are good examples of 
maculae. Under the same term may be included the circumscribed 
discolorations due to extravasation of blood into the tissue of the skin. 
But these are better known by special names. Minute extravasations, 
from about a line in diameter downwards, are designated (from a sup- 
posed resemblance to flea-bites) petechice; larger patches of extravasa- 
tion, such as may be due to the coalescence of several petechia?, are 
called vibices; and such as present the ordinary characters of bruises 
are known as bruises, or ecchymoses. It may here be added that the 
term stigma is sometimes employed to indicate small patches or spots 
of vivid but readily effaceable redness, due to congestion merely, which 
appear suddenly and are often found to precede the development of 
vesicles or papules or the pocks of vaccinia or small-pox ; and that the 
term areola or halo is applied to the ring, more or less broad, of red- 
ness which so often surrounds a definite spot of inflammation. 

Willan's eighth order of skin diseases was that of the maculw, and 
included, amongst other affections, freckles and the various forms of 
birth-mark. 

2. Exanthema or Rash. — These words are employed, not in reference 
to individual spots of disease, but in reference to a more or less general 
eruption of spots or patches, which are inflammatory, and variously 



280 



DISEASES OE THE SKIN. 



grouped, and, in the first instance at all events, red, fading on pressure, 
and but little elevated above the general surface of the skin. The 
exanthemata formed the third of Willan's orders ; and he included in 
it measles, scarlet fever, nettle-rash, roseola, purpura, erythema, and ery- 
sipelas. It is obvious, however, that he has here grouped together 
affections of the skin some of which have little in common with the 
others, and that he has excluded others which should be included 
amongst the exanthemata. Thus purpura is in no sense an exanthem, 
and erysipelas and erythema have no^more right to that name than has 
acute eczema or impetigo. On the other hand, the eruptions of vari- 
cella and small-pox, and especially that of typhus, should certainly be 
regarded as exanthems. The term exanthem, indeed, should be exclu- 
sively applied to the several eruptions which attend and characterize 
the infectious fevers. 

3. Papula or Pimple. — This is a small elevation at the surface of the 
skin, generally acuminated or pointed, but sometimes rounded, and 
rarely exceeding the size of a large pin's head. It is very commonly 
congested, but by no means invariably so, and often attended with much 
itching. Papules are produced in various ways. In the condition 
known as goose's skin there is a temporary production of them at the 
orifices of the hair-follicles in consequence of the contraction of the 
arreetores pili; and in the same situation papules often occur due to 
the concentric accumulation of epidermis and sebaceous matter, en- 
tangling young hairs, in the common orifices of the hair-follicles and 
sebaceous glands. The pearly accumulations so common in the seba- 
ceous glands of the eyelids constitute another form of papule. The most 
important forms of papules, however, are those which originate in en- 
largement of the normal papillae of the skin and those which result from 
inflammatory exudation into the substance of the cutis. 

The papulce constituted Willan's first order, and comprised the va- 
rious forms of disease known as strophulus, lichen, and prurigo. 

4. Tubercles are solid elevations of the cutis, ranging roughly between 
the size of a hazel-nut and that of a papule, varying considerably in 
form and texture, and being for the most part more or less permanent. 
As to form, they are sometimes hemispherical, sometimes nearly glob- 
ular and attached by a comparatively narrow base, sometimes conical, 
sometimes lobulated or warty ; and not unfrequently neighboring tu- 
bercles coalesce, and may thus give to extensive surfaces an irregularly 
thickened lobulated character. As to texture, it is sufficient, perhaps, 
to say that tubercles are sometimes syphilitic, sometimes lupoid, some- 
times due to inflammatory changes in sebaceous glands, sometimes 
simple warts. 

The tubercula formed Willan's seventh order, and included boils, 
warts, molluscum, vitiligo, acne, sycosis, lupus, elephantiasis, and 
frambsesia. 

A wheal may be regarded as a form of tubercle. Its special peculiar- 
ities are that it is of very transient duration, and that it forms a flat, 
generally circular, elevation, rarely exceeding a quarter or a third of an 
inch in diameter. It sometimes presents a more or less vivid rosy tint, 
but is frequently pale, and in either case generally surrounded by a 



DEFINITION OF TERMS. 



281 



halo of congestion. It is usually attended with much itching. A wheal 
represents an early stage of inflammation ; and the swelling which 
characterizes it is doubtless due to effusion from the vessels of the part. 
Wheals may run together, and thus form bands or patches of consider- 
able extent. 

5. Vesicles consist of small accumulations of fluid, generally be- 
tween the horny layer of the epidermis and the rete mucosum. Indi- 
vidually they vary, for the most part, from the size of a pin's head 
downwards ; but they may be larger than that, and by mutual coales- 
cence may form a* more or less continuous tract of some extent. They 
generally stand out prominently from the surface; but when the horny 
layer of the cuticle is thick, as on the palm and sole, they often pre- 
sent no elevation whatever, and can be recognized only by the peculiar 
grayish or bluish tint which they present. The amount of fluid rela- 
tively to the solid constituents of vesicles varies very much; and espe- 
cially this is so if (as is usual) the vesicles are of inflammatory origin, 
inasmuch as the fluid effusion is then often associated with manifest 
thickening of the subjacent cutis and with overgrowth of the involved 
epidermis. Indeed, owing to this circumstance, the distinction be- 
tween vesicles and certain forms of papules becomes purely arbitrary. 
Certain vesicles (sudamina) appear to be simply due to accumulation of 
perspiration between the layers of the epidermis, and their contents 
are pellucid, and like the perspiration itself, acid. Generally, however, 
vesicles are the result of inflammation, spring up therefore on a con- 
gested surface, and present contents which are alkaline, and which, 
according to their age or other circumstances, are transparent or milky, 
or tinged with the coloring matter of the blood. 

The vesiculce formed Willan's sixth order, and were made to include 
varicella, vaccinia, herpes, rupia, miliaria, eczema, and aphtha. 

6. Bullce or blebs may be regarded as having the same relationship 
to vesicles that tubercles have to papules. The line of separation be- 
tween vesicles and bullae is quite artificial; generally speaking, how- 
ever, a vesicle the size of a split pea would be termed a bulla. Bullse 
vary generally perhaps between this size and that of half a walnut. 
Occasionally they attain the bulk of an orange. But when of this large 
size they are very often elongated and even sinuous as to their base, 
and their elevation is proportionately reduced. Their contents are 
identical with those of vesicles. 

The bullce were Willan's fourth order, and included pemphigus and 
pompholyx — affections which are now regarded as identical. 

7. Pustules are accumulations of pus subjacent to the epidermis. 
They vary much in size and form, and also in the degree in which 
they involve the deeper tissues of the skin. They sometimes commence 
as vesicles, the contents of which become gradually converted into a 
puriform fluid ; but very frequently they are purulent from their com- 
mencement. They are generally covered, as vesicles are, by the horny 
layer only, sometimes, however, by the whole thickness of the epidermis. 
The inflammation attending the formation of a pustule is much more 
intense than that which causes a vesicle or bulla, and consequently 
we find, as a rule, much more marked congestion, thickening, and 



282 



DISEASES OF THE SKIN. 



induration of the surrounding and subjacent parts in the former than 
in the latter case. 

The pustulce were Willan's fifth order, and included impetigo, por- 
rigo, ecthyma, variola, and scabies. 

8. Fur jura or scurf is the name given to the thin bran-like scales, 
which separate from the surface of the skin on the subsidence of many 
of the exanthems, and which so commonly form upon the scalp. Scurf 
consists either of thin plates of epidermis or of a mixture of epidermis 
and sebaceous matter. 

9. Squamce or scales only differ from scurf in the fact that the 
plates of detached epidermis which constitute them are of larger size. 
They vary, however, considerably, both in size, thickness, color, and 
consistence. Thus, they may be as much as a square inch in area, or 
even larger than that ; they may be as thin as flakes of scurf or several 
lines in thickness, in which latter case they are always more or less 
distinctly laminated ; they may have the color of the skin, or present 
various tints of yellow or brown ; and they may be soft or hard, friable 
or tough. Some of these peculiarities depend on the amount of fluid 
which has been diffused amongst the epidermic lamina? during the 
process of their formation. The detachment of scurf or scales is called 
desquamation. 

Willan's second order was that of squamce, and comprised lepra, 
psoriasis, pityriasis, and ichthyosis. 

10. A scab or crust is a concretion formed upon some diseased sur- 
face by the drying up of the exudation which has taken place from 
it, and generally therefore comprises some of the normal elements of 
that surface, namely, epidermis and sebaceous matter. The exudation 
may be either serum, pus, or blood, alone or combined in various pro- 
portions; and it is obvious that, according as these occur singly or are 
intermixed, or combined with sebum or epidermis, will the color and 
other physical characteristics of the resulting scabs vary. Serum alone 
dries into thin yellowish or brown translucent flakes, pus alone into 
greenish scabs of some thickness, and blood into crusts which are black 
or nearly so. The admixture of sebum with serum or pus imparts to 
the resulting scab the color and general aspect of gum or honey, and 
that with blood a brown or red tint. When many particles of epidermis 
are mixed with simple serous exudation, as in cases of acute eczema, 
the concreted product often assumes a powdery character, and the color 
of brimstone. Crusts vary much in thickness, and are occasionally of 
conical form. 

It is needless to discuss the meaning of the terms excoriation, fissure, 
ulcer, citratrix, and many others which are in common use and gen- 
erally understood. 

Tendency of Spots and Patches of Skin Disease to assume a Circular 

Form. 

Before proceeding to the description of the various diseases of the 
skin, it may be worth while to point out that, while eruptions present 
great varieties of grouping or arrangement, the individual spots or 



ERYSIPELAS. 



283 



patches have almost invariably a rounded form, and that as they grow 
they maintain that shape unless the form of the surface on which they 
are situated, or the direction of its grooves, or the union of neighboring 
patches with one another, interferes with their regular development. 
Thus a vesicle, a bleb, a pustule, a papule, or a tubercle is almost 
invariably circular in the first instance ; so is a patch of erythema, 
lepra, or pityriasis ; and so also are the vegetable parasitic affections. 
In many cases, moreover, there is a tendency for the central part of 
such a patch to undergo resolution whilst its periphery is extending ; 
and under such circumstances it not unfrequently happens that the 
enlarging ring breaks up into fragments, and that some of these frag- 
ments form the starting-points of other circles or segments of circles. 
It is easy to understand from this statement how the sinuous, ser- 
pentine, and other curious forms which skin diseases frequently 
assume are produced. 



ERYSIPELAS. 

Definition. — An acute inflammation of the skin, originating for the 
most part in the neighborhood of wounds or sores, attended with much 
redness and infiltration and severe febrile disturbance, and character- 
ized by a marked tendency to spread over the surface, and (especially 
in the presence of wounds) to become contagious. 

Causation. — Erysipelas is either traumatic or idiopathic; that is, 
it occurs either in connection with wounds, or it arises apparently 
spontaneously on surfaces which were previously sound. The former 
variety may, therefore, become developed on any part of the body on 
which wounds have been inflicted, or anywhere where conditions 
equivalent to wounds exist, as for example, in connection with other 
forms of cutaneous disease, and about the umbilici of newly-born 
children ; further, erysipelatous inflammation, or a modification of it, 
may attack parturient women. Idiopathic erysipelas occurs most 
frequently on the face. That erysipelas is highly contagious among 
surgical patients, and that its presence in a lying-in hospital induces a 
rapidly fatal form of puerperal fever among the mothers, and erysipelas 
of the newly-born infants, are facts now entirely beyond dispute. It 
is obvious, therefore, that in these cases the disease is propagated by 
the actual transmission from the sick to the healthy of some poisonous 
matter capable of reproducing it ; and from the circumstance that the 
erysipelatous inflammation always begins at the very spot where a 
wound or rawness exists, it seems only reasonable to assume that the 
poison has been inoculated at that spot. It is by no means clear that 
erysipelas spreads in the same way to those whose skin and mucous 
involutions are sound. No doubt many, and apparently very striking 
examples, of such spread are recorded, but, on the other hand, good 
authorities deny its occurrence, and certainly it is very far from 
common. 

In close relation with the subject which has just been considered is 



284 



DISEASES OF THE SKIN. 



the question as to whether erysipelas is to be regarded as a specific 
fever or a mere local inflammation. The former view is generally 
maintained, at all events in this country ; and the chief grounds on 
which it rests are : first, the manifest contagiousness of the disease 
under certain conditions ; second, the existence, which is obvious in 
idiopathic cases, of a distinct, though short, stage of incubation ; third, 
the affirmed enlargement and tenderness of lymphatic glands, prior to 
the appearance of the skin affection, indicating that the erysipelatous 
inflammation is secondary to constitutional disturbance; fourth, the 
discovery of bacteria in great abundance in the inflamed tissues and 
in the lymphatic spaces and vessels connected with them, and the fact 
that these bacteria may be propagated, with the inflammation which 
they accompany, by inoculation upon the lower animals ; and, lastly, 
the close resemblance which exists between the general morbid 
anatomy and symptoms of this disease and those of the specific fevers. 
The arguments in favor of its being a non-specific and local disease, in 
the sense in which pneumonia and nephritis are non-specific and local 
diseases, are chiefly the following : first, the fact that the disease 
appears to arise constantly from exposure to cold and various other 
non-specific causes ; second, that a previous attack, so far from pre- 
cluding subsequent attacks, as is generally the case with the infectious 
fevers, encourages them, as is the common rule with non-specific in- 
flammations ; third, that contagiousness is not an attribute of the specific 
fevers only, for that many varieties of simple inflammation, catarrh, 
ophthalmia, and the like, are apt to spread by contagion ; and lastly, 
that the symptoms and morbid processes which attend erysipelas can 
be fully accounted for as being the consequences of the local inflamma- 
tion. We agree with Hebra in the belief that erysipelas is not a 
specific fever, but a local disease ; that is, a local disease in the same 
sense as inflammations of the lungs and of other organs are local dis- 
eases. 

Apart from contagion, to which, as we have shown, a large propor- 
tion of cases of erysipelas are due, the causes of the disease seem to be 
identical with those of other forms of inflammation, especially expo- 
sure to cold and atmospheric changes generally, and local irritations of 
various kinds. The causes which predispose to it are partly breaches 
of surface, partly constitutional conditions, such as those which result 
from long-continued indulgence in drink, and poor living. 

Morbid Anatomy. — The earliest local changes indicating erysipelas 
consist in a circumscribed blush of more or less vivid redness, which 
fades on pressure, and accumulation of inflammatory products — lymph 
and corpuscles — in the substance of the cutis and subcutaneous con- 
nective tissue. The inflamed patch is consequently thickened, hard, 
and brawny. Its margin is well-defined, and obvious both to the eye 
and to the touch. The character of its surface varies very much 
according to the part of the body which is affected. If the skin be 
smooth and delicate, the inflamed patch becomes yet smoother and 
shining ; if the skin be coarse, all its markings are apt to become mag- 
nified and the coarseness of surface therefore exaggerated. The patch 
gradually spreads by continuity to the surrounding healthy parts, and 



ERYSIPELAS. 



285 



thus increasing in size may ultimately involve a very large area; the 
entire surface of a limb, for example, or that of the head and face, and 
occasionally (it is said) the surface of the whole body. As it spreads, 
however, the parts first affected undergo changes, the tension dimin- 
ishes, the redness becomes less vivid and assumes a yellowish or 
brownish tint, and resolution, preceded by desquamation, presently 
takes place. We thus find that all stages of the disease may be present 
at the same time. Occasionally erysipelas (which is then termed 
erratic) disappears in one part and breaks out elsewhere, and may thus 
be prolonged by successive outbreaks. 

The intensity and results of the inflammatory process vary consider- 
ably in different cases. In some the amount of inflammation present is 
no greater than that which attends the affections which we shall shortly 
describe under the name of erythema. In some cases the effusion 
(which is always present in some degree) is so abundant that it infil- 
trates the subcutaneous connective tissue, and well-marked oedema 
becomes developed. This complication is common wherever the cutis 
is thin and the subcutaneous connective tissue abundant and lax, as 
they are in the eyelid and scrotum. In some cases the inflammation 
goes on to the formation of pus ; and this, like the oedema, occupies 
mainly the subcutaneous tissue. The suppuration is frequently dif- 
fused ; but sometimes, and especially in the eyelids and elsewhere in 
the face and head, forms circumscribed abscesses. In other cases 
again, mainly in connection with suppuration, the connective tissue 
sloughs. Further, in these latter cases, but not in them exclusively, 
the skin itself sometimes becomes gangrenous. When oedema, or sup- 
puration, or sloughing is in progress, the inflamed surface becomes 
paler, duller, perhaps more or less livid, and acquires a soft boggy feel, 
or pits on pressure. 

We have already spoken of some of the conditions presented by the 
surface of the skin. We may add that vesicles and bullae not unfre- 
quently form in the course of erysipelas, that they may become con- 
verted into pustules, and that subsequently excoriations and scales and 
crusts necessarily make their appearance. [To this variety of erysipe- 
las the name erysipelas phlyctenoides was formerly applied. It is 
now called by Hebra E. vesiculosum, E. bullosum, E. pustulosum, or E. 
crustosum, according to the appearance it presents when it comes under 
observation.] Bullae containing sanious fluid also accompany the 
progress of superficial gangrene and of subcutaneous sloughing. 

Although erysipelas is commonly limited in depth by the fascia?, it 
is not invariably thus limited ; and consequently we sometimes find 
that subjacent organs become seriously affected. Thus it is possible 
for erysipelatous inflammation of the surface of the trunk to produce 
inflammation of the peritoneum, pleurae, or pericardium ; for erysipelas 
of the neck to cause oedema of the larynx ; and for erysipelas of the 
head to induce meningeal inflammation. Again, erysipelas not unfre- 
quently creeps into the mucous orifices which happen to be situated in 
its vicinity. Thus it may spread into the auditory meatus, causing 
inflammation of the ear, or into the nose or mouth and hence to the 



286 



DISEASES OF THE SKIN. 



fauces and larynx ; on the other hand, cutaneous erysipelatous inflam- 
mations may be produced by extension of faucial, aural, and other such 
inflammations. 

There is an unquestionable tendency in erysipelas for the veins, and 
especially for the absorbents, to become affected. As regards the 
absorbents, indeed, it is not only common to trace red lines from the 
seat of inflammation to the nearest glands, which become enlarged and 
tender; but some authors go so far as to maintain that a patch of ery- 
sipelatous inflammation is always preceded by inflammatory enlarge- 
ment of the neighboring or nearest lymphatic glands. Phlebitis, again, 
with suppuration in or around the veins, occasionally takes place, and 
occasionally pyaemia. 

Repeated attacks of erysipelas lead to permanent thickening and 
induration, and sometimes to very considerable overgrowth of the skin 
and subjacent connective tissue. Indeed, according to Virchow, it is 
owing to such repeated attacks that the hypertrophy of these parts 
which characterizes elephantiasis is mainly due. 

There is no special affection of internal organs in erysipelas. In 
the early stages of the disease the blood contains an excess of fibrin 
and of white corpuscles ; but subsequently it tends to assume the 
characters commonly observed in the latter stages of febrile disorders. 
Post mortem it is generally found dark, and fluid or pitchy, with little 
tendency to coagulate, and still less to the separation of fibrin. It 
stains the inner surface of the heart and vessels. The organs are gen- 
erally soft, and the lungs, liver, kidneys, and especially the spleen, 
congested. Pneumonia is not uncommon. Decomposition is rapid. 

Symptoms and Progress. — The symptoms of erysipelas are mainly 
those of the local inflammation and of what is called inflammatory 
fever ; but they are often complicated with those of intercurrent lesions, 
and vary in their severity, both actively and relatively, according to 
the intensity of the inflammation, its extent and its situation. In 
idiopathic erysipelas the local signs are generally preceded by an 
interval, varying from a few hours to two or three days, in which the 
patient experiences slight febrile symptoms, sometimes rigors ; and in 
which, according to certain authors, some swelling and tenderness of 
lymphatic glands may be detected. At the end of this time an inflam- 
matory blush appears, generally on some part of the face, attended 
with heat and tingling, and tenderness on pressure. With the appear- 
ance and extension of this, the febrile symptoms increase ; there are 
headache and pains in the limbs, rise of temperature with dryness of 
skin, rigors, often increased rapidity of pulse, furring of the tongue with 
thirst, loss of appetite and nausea or sickness, generally some constipa- 
tion, occasionally, however, diarrhoea, and scanty high-colored urine. 
There may be some degree of drowsiness by day, but the sleep at night 
is restless and disturbed with dreams. If the case be mild, the symp- 
toms may subside and the patient become convalescent in the course of 
two or three days. If the inflammation still continue to spread, and 
at the same time to increase in severity, the pulse becomes rapid and 
feeble, the respirations hurried, the tongue more thickly coated and 



ERYSIPELAS. 



287 



dry ; and delirium, at first only when the patient is dropping to sleep 
or waking, and subsequently eonstant, makes its appearance. Some- 
times at this period diarrhoea occurs; and the patient's evacuations may 
be passed unconsciously. At this point again (that is, at the end of 
six or seven days) the patient may begin to amend. When, however, 
from the inherent severity of the attack, or from other circumstances, 
the case takes an unfavorable course, the symptoms assume more or 
less rapidly a typhoid character — marked mainly by great failure of 
muscular power, tremulousness of limbs, dry black tongue, entire want 
of control over the evacuations, and delirium, which is generally low 
and muttering, sometimes busy, like that of delirium tremens, and occa- 
sionally violent and maniacal. As the fatal end approaches, the tem- 
perature often rises, the skin becomes bathed in sweat, the pulse rapid, 
perhaps irregular, and almost imperceptible, the respirations quick and 
noisy, and the delirium passes into coma. 

The temperature which attends erysipelas is always above the nor- 
mal, but rarely exceeds 106°, and although it is liable to considerable 
variation, there is a general tendency to an evening rise and a morning 
fall. The urine, which is always scanty, and presenting an excess of 
urea and diminution of chlorides, often contains small quantities of 
albumen between the fourth and seventh or eighth day of the disease. 
The motions are generally dark-colored, watery, and very fetid. The 
course and event of the disease are often modified by the association 
with it of the various complications which have been previously enu- 
merated ; thus oedema of the larynx and congestion of the lungs will 
each add symptoms and dangers of its own to those due to the simple 
erysipelas. And in the same way inflammation of the membranes of 
the brain, phlebitis, and pyaemia will each bring its characteristic indi- 
cations. Further, the health and circumstances of the patient at the 
time of seizure for the most part largely modify the character and 
severity of his attack. 

Erysipelas which seems to affect the cutis only is termed simple ery- 
sipelas ; when the subcutaneous connective tissue is largely involved 
as well, the affection is called phlegmonous erysipelas; when much 
oedema, or suppuration, or sloughing takes place, the erysipelas is often 
termed cedematous, suppurative, or gangrenous, as the case may be. It 
need scarcely be said, however, that these distinctions are essentially 
artificial, that the various forms of erysipelas run into one another, and 
that in many cases examples of several, or all of them, may be present 
at the same time. 

Treatment. — Having regard to the tendency which erysipelas mani- 
fests to become contagious, it is always important that those who are 
attacked with it should be removed from the neighborhood of all such 
as are especially liable to contract it, and that, in fact, all those pro- 
phylactic measures should be adopted which have been already recom- 
mended in reference to the infectious fevers. The local treatment in 
mild cases is of little importance, and even in severe cases has perhaps 
little influence. By some the application of collodion, by others that 
of nitrate of silver in the form of a saturated solution, by others that 
of solution of sulphate of iron, of tincture of iodine, or of mercurial 



288 



DISEASES OF THE SKIN. 



ointment, has been strongly advocated. Flour, dusted thickly over the 
surface, is recommended by others. There is an obvious disadvantage 
in employing any application which conceals or masks the diseased 
surface, for which reason several of the above applications are objec- 
tionable, even if useful on other grounds. Mild astringent lotions and 
ointments, such as those of lead, zinc, and iron, are probably as useful 
and convenient as any. Cold-water dressing, which has commonly 
been discountenanced in this country, is strongly recommended by 
Hebra. Warm applications and poultices are not generally desirable. 
It is rarely needful to abstract blood locally, or to make incisions, 
except for the purpose of letting out matter, or to relieve tension. In 
reference to the internal treatment of the disease, we must recollect 
that mild cases get well spontaneously, and that more serious cases 
very soon present symptoms indicative of great debility and of blood- 
poisoning. For these reasons it seems obvious that depletion can never 
be necessary, but that, as a rule, the strength of the patient should be 
sustained, and the free action of his excretory organs encouraged. To 
support strength such nourishment as he can bear should be adminis- 
tered frequently, and in small quantities. Milk, eggs, beef tea, arrow- 
root, sago, and the like, are most suitable for the purpose, and if the 
pulse be failing, and the tongue dry, brandy, wine, or ale (if the pa- 
tient prefer it) should be added at frequent intervals. To promote the 
action of the emunctories, mild purgatives should, if necessary, be 
occasionally administered. Mild diuretics and diaphoretics, and better 
still, abundant nutrient fluids should be given to promote the flow of 
urine and of perspiration. Ammonia, camphor, iron, quinine, have 
all been employed in the treatment of erysipelas, and all are recom- 
mended. It is questionable, however, whether any one of them is of 
material use during the febrile stage of the disease. Tonic medicines 
are, of course, highly valuable during convalescence. Hyoscyamus 
and opium are not generally indicated, and must always be given with 
caution. In some cases, however, where there is great irritability, and 
where there is a persistent want of sleep, they or chloral hydrate or 
other sedatives are valuable. 



CARBUNCLE. (Anthrax.) BOIL. (Furunculus.) 

Definition. — A boil or carbuncle is an intense inflammation occupy- 
ing, within a very well-defined area, the entire thickness of the skin 
(inclusive of the subcutaneous connective tissue), and attended almost 
always with circumscribed suppuration and the formation of a slough. 

Causation. — Boils and carbuncles are usually considered to be con- 
stitutional disorders ; and undoubtedly they are common in persons of 
broken-down constitutions, and in those who are recovering from dis- 
eases of various kinds. Diabetic patients are said to be liable to them. 
But, on the other hand, they are very common in persons who appear 



CARBUNCLE — BOIL. 289 

to be, otherwise, in perfect health ; very often occur in those who suffer 
from acne and other forms of skin disease • and are certainly frequently 
induced by local irritation, by friction, poultices, and the soakage of 
dead bodies (as in persons who perform post-mortem examinations). 
It cannot be denied that there is, in many cases, a predisposition to 
boils and carbuncles, and that this predisposition may be induced. 
We are disposed, however, to regard the disease as essentially local, 
and due to the operation of local causes ; and believe that, like acne, 
it is mainly an affection of the sebaceous glands and their surroundings. 

Morbid Anatomy. — The morbid process commences with circum- 
scribed thickening and induration of the deeper tissues of the skin, 
attended from the beginning, or followed soon, by a little elevation of 
the skin and redness; it increases more or less rapidly in area and 
thickness, and consequently in prominence, until, at the end of a few 
days, it has attained its full development. It then occupies a more or 
less circular area; varies in diameter from half an inch to three or four 
inches or more ; is intensely congested and surrounded with a more or 
less broad areola of congestion and often much oedema; and forms 
above the surface a considerable elevation, which is conical or flat, ac- 
cording as the area involved is small or large, and presents on the top 
a vesicle or group of vesicles, containing serous or sanious fluid or pus. 
Each vesicle soon bursts, discharges its contents, and exposes in its 
floor a small round orifice, from which, even at this time, an ash- 
colored slough protrudes. When there are more vesicles than one, 
they generally speedily run together ; and then by sloughing of the 
intervening papillary layer of the cutis the subjacent orifices soon 
coalesce, and thus form a more or less extensive irregular excavation, 
the floor of which is formed as are the floors of the primary orifices by 
underlying sloughing tissue. The slough which is thus exposed has 
been gradually forming during the development of the disease, and in- 
volves the deeper structures of the skin and sometimes subjacent parts ; 
mainly, however, it consists of connective tissue saturated with pus, 
and presenting a yellowish or grayish color, and a resemblance to 
wash-leather. It now becomes gradually detached from its bed, and is 
at length discharged through the orifice which has formed over it. After 
its detachment the excavation which it leaves becomes filled with gran- 
ulations, the inflammatory thickening of the surrounding tissues dimin- 
ishes, and the parts gradually return to their normal condition, except 
that a permanent scar remains. The distinction between a boil and 
a carbuncle is quite arbitrary ; a boil is comparatively small, generally 
conical in shape, and opening by a single orifice; a carbuncle is dis- 
tinguished by its size and flatness, and especially by the formation of 
more orifices than one, and the presence of superficial gangrene. Car- 
buncles are especially apt to appear in the median line of the trunk 
behind, inclusive of the nape of the neck. They sometimes attack the 
lips (more particularly the upper lip), and are then characterized by 
great malignancy. The lymphatics and veins are very apt to become 
inflamed in these affections ; and of carbuncle, especially pyaemia, is a 
very common sequel. 

Symptoms. — The local symptoms are heat and aching, with throbbing 

19 



290 



DISEASES OF THE SKIN. 



and great tenderness, which are often followed by pain and redness 
along the lymphatics of the part, and pain and swelling in the nearest 
lymphatic glands. There is generally, even with a boil, some amount 
of febrile disturbance; and with a carbuncle the febrile symptoms may 
be very severe. The general symptoms indeed are in this latter case 
almost exactly like those which attend the progress of erysipelas, and 
may be at least as severe as those of the severest forms of that disease, 
and the consequences may be fully as grave and fatal. 

Treatment — The general treatment of patients suffering from car- 
buncle should be identical with that of patients laboring under erysip- 
elas. The local treatment generally recommended is that by free 
incisions, which, if the carbuncle be large, should be crucial. The pain 
and tension are greatly relieved by incisions; but it is doubtful if the 
progress of the disease is checked or its course materially modified by 
them. Caustic applications, especially the free use of caustic potash, 
are recommended by some. Poultices and warm-water dressings are 
generally of service. Hebra strongly advocates the use of cold in the 
form of compresses saturated with ice-cold water, to be applied so long 
as they are not disagreeable to the patient. 

In the treatment of boils (which often show a tendency to recur) r. 
many internal medicines, among others yeast, quinine, and mineral i 
acids, have been recommended, with the object of preventing that re- 
currence. It is, however, more than doubtful whether any of them 
has a specific influence. It is, of course, with this object always desira- 
ble to treat any associated malady which may keep up a condition of s 
system favorable to the development of boils. Boils may be treated 
locally on the same principle as carbuncles ; and it may be added that 
some authorities believe they may be made to abort by the early appli- 
cation to them of strong ammonia, caustic potash, acid nitrate of mer- j 
cury, or some other form of caustic. 



ERYTHEMA. ROSEOLA. URTICARIA. PITYRIASIS. 

The affections to which the names here quoted are applied embrace ; 
a considerable number of morbid states of the skin which resemble one | 
another in the facts that they are for the most part slight, superficial, 
and essentially short-lived inflammations; that they have little or no 
tendency to suppuration, ulceration, or gangrene, but end usually in 
furfuraceous desquamation ; and that they are often variously figured 
and distributed, and never contagious. 

There is great confusion amongst dermatologists as to the distinctions 
between erythema and roseola. Dr. Willan describes the former as a 
nearly continuous redness of some portion of the skin, and the latter as \ 
a rose-colored efflorescence variously figured. But even he includes 
under the head of "erythema" affections which, according to his defini- 
tion, should be varieties of roseola; while, on the other hand, several \ 
conditions are now universally termed roseola which, according to the ! 



ERYTHEMA, 



291 



same definition, ought to be regarded as erythema — we refer to so-called 
"roseola cholerica" and "roseola vaccinia." The formation of distinct 
wheals is the special characteristic of urticaria ; but wheals are formed 
under so many various conditions, and so closely resemble some of the 
eruptions which are termed erythema, that it is impossible to draw 
any sharp line between them. For these reasons we propose to discuss 
erythema, roseola, and. urticaria together; and, 'although we shall pre- 
serve the names, we shall regard them as indicating trivial, and in some 
cases imaginary, distinctions between things which are essentially the 
same. Pityriasis we regard simply as the desquamating stage of the 
various forms of erythema. 

Causation and Description. — Some of these affections are of local 
origin, due to the action of direct irritants ; but many of them, as is 
shown by the attendant circumstances, and by their simultaneous sym- 
metrical development, are distinctly traceable to caus.es acting from 
within. The former, if extensive, may be attended with febrile dis- 
turbance. The latter are generally so attended ; and, indeed, not un- 
frequently appear in the course of some rheumatic, gouty, or other 
inflammatory or febrile attack. The local symptoms are, for the most 
part, itching of a more or less intense character, burning, stinging, and 
occasionally aching. 

1. Erythema simplex is a pretty uniformly diffused redness, occupy- 
ing an area of very variable size and form. The redness is generally 
bright, disappearing on pressure, attended with slight thickening and 
elevation of the skin, and generally presenting a fairly well-defined mar- 
gin. It very often spreads from its primary seat over the neighboring 
skin, and is not unfrequently erratic. There is a very close resemblance 
between certain varieties of erythema and the simplest form of erysipelas. 
Indeed, it is impossible in many cases to distinguish between them. 
One variety of erythema is produced by the direct operation of local 
irritants, as by the application of a mustard-plaster, by the constant 
flow of catarrhal secretions from the nostrils or of saliva from the 
mouth, and in children, when from want of cleanliness the urine is 
allowed to fret the thighs, groins, and other neighboring parts. Inti- 
mately related to this is the condition known as erythema intertrigo, in 
which inflammation is induced either by the attrition of opposed sur- 
faces of skin or by the effect on these surfaces of perspiration which 
accumulates between them and irritates them. This is common in chil- 
dren and fat adults, in the groins and between the upper parts of the 
thighs and the external genital organs, and in fat women between the 
under part of the pendulous mamma and the surface with which it lies 
in contact. The persistence of the cause in erythema intertrigo tends to 
keep up and intensify the irritation; and consequently excoriation and 
ulceration are apt to supervene. The presence of the pent-up and 
decomposing perspiration in these cases often induces a very offensive 
odor. Another variety of erythema is known as erythema Iceve. This 
is the superficial inflammatory blush which often appears in limbs, and 
especially in legs, which are the seat of anasarca. The redness is gen- 
erally somewhat unevenly distributed, and is attended with tenderness 
and itching, tingling or aching. Vesicles, which rupture and allow 



292 



DISEASES OF THE SKIN. 



the escape of the dropsical fluid, are very apt to form on the surface ; 
the inflammation not unfrequently passes into distinct erysipelas, and 
not unfrequently superficial gangrene ensues. A further variety of 
erythema is commonly known by the name of pityriasis simplex. This 
occurs on various parts of the body, but is especially common in the 
form of circular or oval patches on the lips, chin, and other parts of the 
face in children and persons of delicate skin. The patches present a 
slight degree of redness, and are very early covered with thin branny 
scales, or scurf — from which circumstance the name pityriasis has been 
given to them. This affection is also of common occurrence in the 
hairy scalp, when it is usually called pityriasis capitis, or dandriff. In 
this case the branny scales, which form pretty abundantly and, owing 
to the presence of hair, tend to accumulate, contain, as might be ex- 
pected from their soil, a considerable admixture of sebaceous matter. 

2. Erythema Multiforme. — Under this term, which we owe to Hebra, 
are included e. papulatum (in the sense in which Hebra employs that 
term), e. circinatum, e. iris, e. marginatum, and e. gyratum. The ear- 
liest stage of the affection is characterized by the appearance of small, 
flat, circular, congested elevations of the cutis, attended with itching, 
and differing little if at all from wheals (e. papulatum). Their develop- 
ment may cease at this point ; but in most cases they pass on to a 
second stage. The wheal gradually increases in area until perhaps it 
measures half an inch or an inch in diameter, and while it thus in- 
creases, its central portion probably subsides, its periphery forming a 
congested tumid ring (e. circinatum) ; or the enlargement of the inflamed 
patch is effected by the development of successive concentric rings of 
inflammation, separated by zones of fairly healthy skin, and the affec- 
tion known as e. iris results. Further, the spots of erythema papu- 
latum, and the patches of the circinate form of the affection, which 
may attain much larger dimensions than have been above assigned to 
them, tend in the course of their development to coalesce with one 
another and thus to cover with more or less uniformity round, oval, 
or sinuously-margined arese of several square inches, which are still 
for the most part characterized, like the spots from which they sprung, 
by a tendency to central subsidence and to marginal extension by a 
broad band of congestion. In their progress these " fairy rings" not 
unfrequently break up into segments, and thus after awhile curved or 
sinuous erythematous bands alone remain. These latter forms of the 
affection constitute e. marginatum and e. gyratum respectively. The 
several varieties of erythema above described occur on various parts 
of the body and are sometimes very extensively distributed ; they are 
most common, however, on the backs of the hands and wrists and cor- 
responding parts of the lower extremities. They are generally attended 
with febrile symptoms, which, if the eruption be extensive, may run 
high, the temperature rising temporarily to 104° or more, and they 
are very apt to be associated with the presence of rheumatism or gout. 
Individually the inflamed patches rarely last more than a week or ten 
days, sometimes not longer than two or three days, and terminate in 
desquamation. The eruption may, however, be continued by succes- 
sive crops for several weeks. Occasionally it assumes a chronic form, 



ERYTHEMA. 



293 



or the patient remains for years liable to more or less frequent outbreaks. 
It sometimes happens that the wheals or rings of this affection become 
the seat of cutaneous haemorrhage {purpura urticans f) which is generally 
in the form of minute coalescing points and for the most part limited 
to their central areae, and that this leads sometimes to the death of the 
involved cutis and the separation of eschars, sometimes to the develop- 
ment of sanguinolent blebs, sometimes to unhealthy ulcers. Further, 
vesicles or bullae, containing limpid fluid, are not unfrequently developed 
in more or less abundance upon the surface of the erythematous patches 
(herpes and pemphigus). 

3. Erythema nodosum is characterized by the appearance of round 
or oval red patches varying, roughly speaking, from J inch to 1J inch 
in diameter. They rise in a lenticular form above the surface on which 
they are developed, and are consequently most elevated at the centre, 
where also the redness is most intense ; and in both of these respects 
they fade away gradually at the margins. They are hot, hard and 
tense to the feel, and to the patient tender and attended with aching. 
They chiefly occur scattered over the anterior part of the leg, between 
the ankle and knee, but sometimes are observed on the lower part of 
the thigh. They occasionally occur also on the corresponding parts 
of the arms ; and in very rare cases are scattered over the whole sur- 
face of the body, inclusive of the fingers, toes, and face. The patches 
generally increase in number day by day for a few days — each one 
lasting perhaps a week. They become dusky in color after a day or 
two, and generally acquire a bluish aspect when exposed to cool air; 
they present successively the greenish and yellowish tints of fading 
bruises, and end with desquamation. Erythema nodosum is for the 
most part preceded and attended by febrile symptoms, and is not un- 
frequently associated either with rheumatic pains or distinct rheuma- 
tism. It is most common in young persons above the age of puberty, 
especially in those of the female sex. The affection described by Wilkin 
under the name of e. tuberculatum is a modification only of e. nodosum. 
We believe, too, that the roseola autumnalis of the same author is essen- 
tially the same disease; and we may add that there is little, if any, 
difference between a chilblain (pernio) and a patch of e. nodosum. 

4. Erythema fugax is the name given to the evanescent patches of 
redness which appear on the face, neck, chest, and other parts in 
hysterical and dyspeptic patients. This is closely related to the 
patches of redness, termed roseola, which are sometimes observed in 
cholera, in small-pox, and other fevers, and may be held to include 
those which are so commonly associated w T ith the vesicular and other 
inflammatory skin diseases of young children. 

5. Roseola, as has been already explained, is a name of common and 
somewhat indefinite application. This, or still better perhaps the name 
roseola rubeoloides, may properly be applied to an affection of the skin 
of which Willan seems unnecessarily to make two varieties, namely, 
r. 03stiva and r. infantilis. This rash seems generally to be preceded 
for a day or two by slight febrile disturbance, and, like so many other 
rashes, to make its appearance first on the face and neck, whence it 
speedily spreads over the general surface of the skin. It consists in 



294 



DISEASES OF THE SKIN. 



rose-colored flatly elevated circles, fading at the periphery into the 
surrounding healthy skin, and disappearing on pressure, varying per- 
haps from J to J inch in diameter, and often running together over 
extensive tracts so as to form an imperfect network with scalloped 
interstices. There is often some general but slight tumefaction of the 
surface, and a passing chill is apt to render the rash temporarily of a 
peculiar violet tint. There is not unfrequently some itching ; and the 
fauces are occasionally affected. The affection generally disappears 
within four or five days after the first appearance of rash. It is quite 
unattended with danger, and of little importance, except from its 
resemblance to measles and to rotheln or epidemic roseola on the one 
hand, and to urticaria on the other. 

6. Urticaria or nettle-rash is an affection which has been subdivided 
by dermatologists into numerous varieties. It seems unnecessary, how- 
ever, to make more than two, namely, u. acuta ovfebrilis, and u. chron- 
ica or evanida. 

The more common form of the disease is u.febriUs. In this variety 
the appearance of the eruption is very often, if not always, preceded by 
more or less febrile disturbance, attended it may be with some degree 
of gastro-intestinal derangement; and these symptoms continue during 
the prevalence of the eruption, which rarely exceeds a few days or a 
week. The eruption, which is preceded by and attended with much 
local heat and itching, generally comes on in the evening or night, and 
disappears in the morning ; and the disease is continued for a few days 
by successive nocturnal outbreaks. In many cases, however, it comes 
out at irregular periods of the night and day. The wheals appear 
quickly, rarely remain out longer than a few hours, and on subsiding 
sometimes leave behind them a slight yellowness of skin and a ten- 
dency to desquamate. They may appear simultaneously or in succes- 
sive crops on any or all parts of the surface ; but are most common on 
the face, the back and chest, and the flexures of the joints. The lips 
and tongue and interior of the mouth are occasionally affected. The 
wheals are sometimes scattered ; more generally, however, they are 
clustered and run together, and then may cover large extents of sur- 
face. Their presence is often attended with much subcutaneous oedema 
and stiffness of parts. Scratching and other forms of local irritation 
tend to increase their size, number, and duration. Occasionally febrile 
urticaria is due to the use of certain alimentary substances which, either 
from some poisonous quality which they have acquired, or from some 
idiosyncrasy in the subject, act in a special way on the system. Shell- 
fish and pork, in its various preparations, are the substances which 
most commonly have this effect. In the severer cases the symptoms 
supervene rapidly, are very grave, and may indeed prove fatal. They 
are mainly rigors, failure of circulation, fainting, precordial oppression, 
vomiting, and difficulty of breathing. They generally subside, how- 
ever, in the course of a few hours. 

Chronic urticaria, which supervenes in some cases on the acute form, 
is generally unattended with marked fever. It shows itself for the 
most part, like that, in successive crops of eruption, which come out 
daily or at irregular intervals, for weeks, or months, sometimes for 



URTICARIA. 



295 



many years. A curious sub- variety of .chronic urticaria is that which 
Sir W. Gull has termed factitious urticaria. Here the eruption, al- 
though it comes out as in other cases in successive crops, is also readily 
produced by pressure or irritation applied to the skin. And thus the 
application of a ligature, or the passage of the finger-nail, is followed in 
a few seconds by the appearance of a line of confluent wheals, with an 
areola of congestion, which remains out for a few minutes and then 
disappears. 

W e may add here that wheals, more or less exactly resembling those 
of urticaria, are very often the result of the operation of local irritants. 
They are common in the morbid condition of the skin known as pru- 
rigo, in scabies, and in phthiriasis. They result also from the prick of 
the ordinary stinging nettle, and from the influence of some species of 
jelly-fish. And again they follow the bites of many insects, such as 
gnats, fleas, and bugs. In this last case, however, the wheals are per- 
sistent, and often last for a week or ten days. They probably consti- 
tute Willan's urticaria ferstans. 

The causes of urticaria are not well understood. We know, as has 
been pointed out, that some of the severer forms of the affection are 
caused by poisonous matters received into the stomach, and acting 
through the medium of the circulatory system. And we are disposed, 
therefore, to assume that urticaria generally must be due to gastro- 
intestinal disturbance. That in many cases it really is so is probably 
beyond doubt. But it is equally certain that, in a large number of 
instances, especially in the chronic forms of the disease, there is no 
indication whatever that the digestive functions are at fault. Mental 
emotion, hysteria, and uterine affections are sometimes assigned as 
causes of urticaria. 

Treatment. — Most of the erythematous inflammations which have 
just been described need little or no special treatment, either local or 
general. Many of them must be regarded as parts, and indeed trivial 
parts, of more serious diseases — such, for example, as rheumatism ; and 
their treatment must merge in that of the more general malady out of 
which they have arisen. For most of them cooling or astringent lo- 
tions, such as cold water or lead-wash, are serviceable and agreeable ; 
but for some of them, more especially e. intertrigo and pityriasis, care- 
ful local treatment is generally essential. In e. intertrigo the affected 
parts should be kept perfectly clean and free from acrid moisture, and 
opposed surfaces separated, if necessary, by a piece of lint anointed 
with some appropriate ointment. Dusting the surface with starch, 
oxide of zinc, fuller's earth, lycopodium or violet powder, or applying 
astringent lotions or ointments, are often valuable measures. In pityr- 
iasis cleanliness is equally essential, and the cure is often aided by the 
use of mild mercurial ointments. When the lower extremities are 
affected with e. nodosum or e. lseve, the patient should keep the recum- 
bent position, with the legs elevated. The general traeatment of these 
various affections should be mildly antiphlogistic and comprise cooling 
drinks and gentle laxatives. In erythema nodosum, however, it is fre- 
quently necessary to have recourse to tonics. And in urticaria, if it 
be either severe or chronic, special measures must be adopted. If, for 



296 



DISEASES OF THE SKIN. 



example, there be reason to suspect its dependence on poisonous sub- 
stances taken into the stomach, an emetic or a purgative may be neces- 
sary ; if there be much abdominal pain, opiates ; if collapse, either 
ammonia, brandy or other stimulants. In the chronic form of the 
disease few remedies have been found useful, but arsenic, mineral acids, 
alkalies, tonics, and change of air have often been recommended. 



PSORIASIS. (Lepra.) PITYRIASIS RUBRA. 

We have shown that one of the events of the various forms of 
erythema is the formation of scurf; we pass, therefore, naturally from 
their consideration to that of psoriasis, which is essentially also a super- 
ficial inflammation of the skin, attended with the development of 
scales. It is thus closely related to pityriasis, and cannot always be 
separated from it. Willan and his followers have distinguished 
psoriasis from lepra, but the distinctions are quite artificial ; and we 
shall, therefore, with Hebra and others, combine them in a common 
description. 

Psoriasis. 

Causation and Description. — This affection is characterized by the 
presence of defined, mostly circular, tracts, in which the cutis is some- 
what congested and raised ; while the epidermis over it is thickened, 
opaque, and tends to separate in large flakes. These, on their separa- 
tion, leave a congested, irritable, and sometimes slightly excoriated 
surface, on which squamae are speedily reproduced. 

It commences with spots or disks of slight congestion, over which, 
almost from the earliest moment, the cuticle assumes a scaly charac- 
ter ; but at first, and while they are in process of enlargement, the area 
of congestion usually extends beyond that of desquamation. 

The patches vary much in size and shape. In some cases they are 
mere papules, a line or less in diameter ; in other cases, they have a 
discoid form, measuring between \ and J inch across ; in other cases 
they form rings between (say) the size of a shilling and that of a 
crown-piece, inclosing a central area of comparatively healthy skin, and 
these rings (especially if they become very large) may break up into 
segments; in other cases, again, partly by coalescence of adjoining 
patches, partly by innate irregularity of growth, they form patches of 
large size and irregular outline, covering, it may be, an entire limb or 
even the whole surface of the body. 

The squamae also vary both in color, in consistence, in thickness and 
in form. These peculiarities are mainly due to the different degrees of 
rapidity with which they are developed, and to the fact that they result 
from an excessive formation and exfoliation of epidermis, among the 
cells of which inflammatory exudation and even the contents of the 
involved cutaneous glands are diffused in various proportions. The 
scales are sometimes white and glistening, like mother-of-pearl; some- 



PSORIASIS. 



297 



times yellow, and more or less waxy in appearance; sometimes brown 
or even black; sometimes close and dense in texture; sometimes fria- 
ble and flaky, or even powdery. In some cases they form an ex- 
tremely thin layer, in others they may be a quarter of an inch or more 
in thickness ; and occasionally, where a virgin patch has been slowly 
enlarging, the accumulated scales on its surface assume the form of a 
limpet-shell. The general outline of the crust will necessarily be de- 
termined by that of the patch on which it is produced. 

The subjacent skin is always more or less distinctly congested and 
thickened ; and very often, when the disease is in an aggravated form 
and has existed for some length of time, tends to become excoriated 
and fissured, and then to exude serum and blood, which, mingling 
with the squamae, form distinct scabs. 

The eruption of psoriasis is peculiarly liable to attack the extensor 
surfaces of the knees and elbows. But it may occur on any part of the 
person, though it is comparatively rare on the face, and still more rare 
on the palms and soles. The hairy scalp is a common seat of the dis- 
ease. The nails also are not unfrequently involved, becoming thick, 
rough, and coarse in texture. It is very apt to be symmetrical. 

Psoriasis presents, as may be supposed from the above account, 
many varieties of character, some of which it may be useful to re- 
member, if only for descriptive purposes. Thus, when it consists of 
an eruption of numerous small spots, it is called p. guttata; when of 
small disks covered thickly with white scales, lepra alphoides or cdphos; 
when of rings, lepra vulgaris; when of segments of circles which have 
coalesced with similar segments of adjoining circles, lepra gyrata; and 
when of irregular patches occupying a large area, p. diffusa. 

The progress of psoriasis is sometimes remarkably acute ; thus, it 
will sometimes come out and become general in the course of a week, 
and disappear with almost equal suddenness at the end of two or three 
weeks. At other times, and much more generally, it is a chronic mal- 
ady ; sometimes persisting for years in two or three situations, as, for 
example, on the knee, or point of the elbow, and presenting periodical 
exacerbations in the spring or autumn ; sometimes occupying large tracts 
of surface persistently (p. inveterata) for many years, or for life. 

The general health of patients suffering from psoriasis is rarely ma- 
terially or even obviously impaired. Occasionally, however, febrile 
symptoms attend its acuter manifestations, and sometimes debility and 
emaciation supervene in the course of long-continued and very severe 
attacks. Yet the remarkable tendency of the eruption to break out 
simultaneously in corresponding situations on both sides of the body, 
and its undoubtedly hereditary character, together with the fact that 
an almost identical eruption attends the constitutional operation of the 
syphilitic virus, point very strongly to the dependence of psoriasis on 
constitutional causes. It must be added that its development and dis- 
appearance are often very manifestly influenced by constitutional modi- 
fications. Thus it occasionally shows itself only during pregnancy, 
disappearing with the birth of the child ; and occasionally, on the other 
hand, those who are subject to it lose it entirely during the period of 
childbearing. It is remarkable how little local discomfort, compara- 



298 



DISEASES OF THE SKIN. 



tively, psoriasis produces ; a little stiffness and a little itching are often 
the only inconveniences complained of. 

Treatment. — The treatment of psoriasis must be considered under the 
heads of local and constitutional. The local treatment consists, first 
of all, in the removal of the scales, which may be effected by warm 
baths or poultices, or by the thorough inunction of oil or ointments of 
various kinds; and then in the application of special remedies, among 
which may be included iodine paint, nitrate of silver, strong solution 
or ointment of subacetate of lead, and especially tar ointment, or other 
equivalent empyreumatic preparations. The constitutional treatment 
most generally resorted to is the exhibition of arsenic in small repeated 
doses. Sometimes tar is administered internally with the same object, 
sometimes tincture of cantharides, sometimes copaiba, and sometimes 
iodide of potassium. Tonics and cod-liver oil are occasionally useful. 
The disease, however, is very apt to resist all treatment, and even when 
a cure seems to be effected it is very often apparent only, and the 
result of the normal periodic retrogression of the malady. 

Pityriasis Rubra. 

Description. — This term was applied by Willan to a variety of that 
form of pityriasis already briefly considered under the head of erythema. 
Hebra, and in this respect we follow him, employs it to designate a 
specific form of skin disease, of rare occurrence, and having a close 
affinity with psoriasis. So far as is known, it appears to commence 
with universal congestion of the skin, followed soon by general ten- 
dency in its epidermic layer to separate in scales. Its progress is slow, 
and it is doubtful whether a cure is ever effected. The redness of the 
cutis, when once established, persists, but is attended with little thick- 
ening or discomfort; and the epidermis continues to desquamate, the 
scales, however, sometimes accumulating in considerable quantity. 
When fully developed, there is nothing except the history and progress 
of the malady to distinguish it from universally diffused psoriasis. 
Patients suffering from it remain apparently healthy in other respects 
for a long time ; but (according to Hebra) they ultimately emaciate, 
become cachectic, and sink from exhaustion. 

The treatment is very unsatisfactory. Arsenic may be tried internally. 
"Warm baths and simple oleaginous applications may afford relief. 



ICHTHYOSIS. 

Under this term are included certain affections of the skin, charac- 
terized by great dryness of the epidermis, with tendency in it to crack 
and scale, deficiency or absence of the sebaceous secretion, and more 
or less horny conversion of the epithelium of the sebaceous follicles. 



ICHTHYOSIS. 



299 



Ichthyosis Simplex or Xeroderma. 

Description. — This is the commonest variety of the affection. It is 
for the most part congenital, and its presence is generally first recog- 
nized by the parents during the first year or two of life, in consequence 
of the harshness and dryness of the general surface of the skin, and the 
difficulty they experience in keeping certain parts of it, such as that 
covering the elbows and that covering the knees, in a cleanly condition. 
In quite young children indeed it only manifests itself by the characters 
just enumerated, and by the tendency of the epidermis to come away 
in flakes. As life advances, the condition of the skin becomes more 
characteristic. The affection is then seen to be general, but differing 
in severity in different parts. It is least marked on the palms of the 
hands and soles of the feet, on the inner surfaces of the wrists and 
arms, and on the inner aspects of the thighs. Here the skin may be 
a little dry only, and differing little in appearance from healthy skin. 
The face is generally rough and dry, and slightly furfuraceous. The 
greater part of the rest of the surface of the limbs and trunk is mapped 
out into irregular polygonal area?, the limits of which are, for the most 
part, determined by the normal creases and folds; and the epidermis of 
these areae, dry, hard, brittle, and somewhat nacreous, becoming partially 
separated at the edges, and sometimes undergoing complete separation, 
gives that scaly character to the surface which allies this disease to 
psoriasis. But the places in which ichthyosis leads to the most striking 
results are the knees, the elbows, and other parts of the surface which 
are naturally apt to become thickened under the influence of pressure 
or friction. Here the epidermis becomes extremely thick and hard, 
generally brown or black from impregnation with dirt, and divided 
even more manifestly than elsewhere into polygonal areae. Wilson 
states that in this affection many of the sebaceous glands are filled with 
a dry hard substance, which often projects from their orifices. 

A condition of skin very closely resembling ichthyosis is often met 
with in the course of chronic wasting diseases, such as phthisis, and is 
sometimes developed with advancing years. 

Persons who suffer from ichthyosis are said to be, for the most part, 
feeble and emaciated. But that is certainly not a universal rule. 
They are often peculiarly subject, however, to suffer from eczema and 
impetigo. 

Treatment. — The congenital disease is incurable, but it may be much 
relieved and rendered tolerable by cleanliness, the frequent use of warm 
baths, and the anointment of the surface with oil or grease, — olive oil, 
neat's foot oil, and the like. 

Ichthyosis Cornea. 

Description. — This is a much rarer affection than the last, and very 
often makes its appearance at a later period of life. It is seldom gen- 
eral, and often appears in scattered patches, which have a tendency to 
spread. It is characterized by the development of prominent, hard, 
dry, horny processes of epidermis, which very often have an exact 



300 



DISEASES OF THE SKIN. 



resemblance to those which appear on the surface of the knee in the 
simple variety of the disease. These are usually grouped together, 
and hence often assume individually an irregular prismatic form, and 
they project sometimes a quarter of an inch or more above the general 
surface. They are partly due to a mere overgrowth of epidermis in 
patches, corresponding to the normal polygonal arese of the skin, but 
are mainly, we believe, connected with the horny conversion of the epi- 
dermic lining of the sebaceous follicles. In this latter case the horny 
outgrowth appears under the form of a comedo-like body, which first 
distends the orifice of the follicle, and then rises above it in a form not 
unlike that of a caraway seed. Presently this becomes detached or 
broken, but the horny matter, still growing upwards and in breadth, 
distends the sebaceous follicle and its orifice more and more, until they 
form a mere shallow pit, surrounded with a tumid ring. With the 
progress of the disease the pit becomes effaced, what was the inner sur- 
face of the follicle becomes level with the surface of the skin, or even 
projects above it, and still produces (but now from a larger area) its 
horny growth. Finally, the tendency to produce a horny outgrowth 
extends from the sebaceous follicle to the epidermis of the portion of 
skin immediately surrounding it. These horny formations absorb dirt, 
and are rendered consequently more or less opaque and black. They 
often become detached, and occasionally then leave the surface from 
which they sprung tolerably healthy. 

Treatment. — No medicine that we know of has any influence in modi- 
fying or curing this affection. It certainly does sometimes die out in 
certain situations, while it advances in others. It is conceivable, there- 
fore, that it might occasionally subside altogether. As a rule, however, 
it is certainly of lifelong duration. The horny growths, nevertheless, 
may generally be removed, and the chief discomfort, therefore, and 
offensiveness of the disease, kept in abeyance, by the frequent use of 
warm baths, and the application of poultices or oil. 



ECZEMA. (Lichen. Strophulus.) 

The first of these affections is vesicular, that is, characterized by the 
development of vesicles upon an inflamed base ; the second of them is 
generally regarded as papular — in other words, as due to the formation 
of solid pimples on an inflamed surface; the last is simply the lichen 
of children. Many modern authorities, however, now regard the vari- 
ous forms of eczema and lichen merely as varieties of the same disease, 
and strophulus a fortiori as a variety of eczema. We adopt this view, 
and combine them in a common description under the general name of 
eczema. 

Causation and Description. — Eczema is an inflammation of the skin, 
for the most part much more acute in its phenomena than psoriasis, 
and attended with much more violent local irritation. It often com- 
mences with itching, but this is soon followed by the appearance of 



ECZEMA. 



301 



minute acuminated papules, which are more or less red from conges- 
tion, which may be either grouped in patches, or scattered, and which 
sometimes (but not by any means invariably) originate at the points 
from which hairs emerge. The papules gradually increase in size, 
sometimes retaining the solid form, sometimes becoming obviously 
vesicular almost from their first appearance. In the former case they 
may attain a line or more in diameter, when their acuminated char- 
acter probably disappears ; more frequently perhaps they retain the 
average size of a millet-seed, and, after having remained out for a few 
days, or a week or two, their redness fades, their surface desquamates, 
and they gradually subside. Where the eruption is essentially vesicu- 
lar, each papule (which is generally intensely inflamed) becomes occu- 
pied or crowned by a circumscribed accumulation of serum, which is 
effused between the horny and the mucous layers of the epidermis. 
The vesicles are rarely larger than a poppy-seed, excepting when they 
are closely aggregated, and neighboring ones coalesce, under which 
circumstances a considerable area may be covered with a low r , undulat- 
ing bleb, pinned down, as it were, here and there, to the subjacent sur- 
face, by the remains of the party walls between adjoining vesicles. In 
this case, also, the eruption may subside at the end of a few days, but 
the appearances which attend its subsidence vary. Sometimes the con- 
tents of the vesicles become absorbed, and desquamation only takes 
place. More commonly the vesicles burst, and the exuded serum, 
mingling with the separating epidermis, coagulates into a scab, the 
character of which depends on a variety of circumstances — among 
others, the part of the skin affected, the cessation or persistence of 
exudation, the entanglement with it of dirt or other foreign matters, 
and the admixture of blood or pus, due to the effects of scratching or 
other local violence. In the simplest case, the scab is often of a sul- 
phur-yellow hue, and more or less powdery. More commonly perhaps 
it is of a dark color, scaly, or gummy, and adherent to the surface. 
On the scalp the crusts are apt to accumulate and to form thick, dirty 
laminae. 

Eczema is liable to become chronic. In some cases, especially in the 
more papular form, the eruption then loses its vivid redness, and the 
surface becomes thickened, rough, scurfy, and fissured. In other cases 
(and this condition supervenes on the vesicular form) large tracts of 
surface become red, excoriated, and moist, and, on close examination, 
may be found to be covered in patches with a thin, opaque, soft, 
epidermic layer which is studded more or less abundantly, especially 
at the edges, with pits (very much like the perforations by which post- 
age-stamps are separated from one another), at the bottom of which a 
red weeping surface is visible. These pits are excoriations and cor- 
respond to vesicles, and in such cases are probably the only representa- 
tives of vesicles which can be recognized. In other cases, again, the 
inflamed surface loses after a time its eczematous condition, becomes 
uniformly inflamed, brittle, and scaly, and assumes characters which, 
apart from the history of the case, are identical with those of chronic 
psoriasis or pityriasis rubra. 

The vesicles or papules of eczema may either be scattered and dis- 



302 



DISEASES OF THE SKIN. 



crete, or they may be collected into groups situated on circular or oval 
arese of small size, or they may occur in irregular clusters, which tend 
themselves to run together, the intervening skin being at the same 
time studded with isolated spots. In the first of these cases the papu- 
lar form of the disease constitutes lichen simplex or strophulus intertinctus 
(red gown or gum); in the second, lichen circumscripta or strophulus 
volaticus ; and in the third, lichen agrius, or strophulus confertus (rank 
red gum). Eczema may be acute or chronic ; the former may last for 
a week or ten days, or more ; the latter consists often in successive out- 
breaks of the acute disease, but includes those cases in which the skin 
assumes the features of psoriasis diffusa, and also the form commonly 
known as eczema rubrum. In this there is general excoriation with 
intense redness, abundant exudation of serum, and the formation of 
numerous red oozing points in place of distinct vesicles. It is most 
frequently seen in typical completeness on the lower extremities of 
elderly persons. 

jNo part of the surface of the body is free from liability to eczema. 
It attacks some parts, however, preferentially, and then often receives 
a local epithet. Thus it frequently occurs upon the hairy scalp (e. 
capitis), constituting a very troublesome and chronic affection ; on and 
in the ears (e. aurium) ; at the edges of the eyelids (e. palpebrarum) ; 
and on the cheeks (e. faciei). It is common too in the axilla and bend 
of the elbow, about the anus, pubes, and outer part of the thigh, and 
in the bend of the knee. The nipples of suckling women, and the 
umbilicus of the newly-born babe are frequently affected. And it is 
not uncommon on and between the fingers. The affections known as 
grocers' itch, bakers' itch, and ivarehousemen's itch are all of them 
eczema or lichen agrius of the backs of the hands and wrists. 

Not unfrequently, when the eczematous inflammation is severe, 
spots of suppuration appear, intermingled with the orignal vesicles 
and papules; and the scales which result become thicker and darker 
than those of uncomplicated eczema. Eczema then approximates in 
its characters to impetigo, and is often consequently termed e. impeti- 
ginodes. 

Eczema, in its various forms, is the most common of all skin dis- 
eases. It is of frequent occurrence in babes and young children ; but 
no age is free from liability to it; and it may break out for the first 
time in extreme old age. It is not an unfrequent attendant on preg- 
nancy and lactation. It is sometimes distinctly hereditary ; and a 
previous attack generally predisposes to subsequent attacks. Its causes 
are not very obvious; occasionally, however, it is clearly produced by 
local irritation — in the head by the constant use of very hard brushes ; 
in the nipples by the irritation of sucking ; between the thighs and 
buttocks and analogous parts by the effects of the local secretions and 
by attrition; and in bakers and others by the irritating substances 
among which they work. Eczema is also frequently induced by the 
presence of scabies or of pediculi. These, however, are not the only 
causes. It is often idiopathic, and is then not unfrequently preceded 
for a day or two by febrile symptoms. It is often ascribed to gout, 



ECZEMA. 



303 



dyspepsia, uterine complaints, teething, and the influence of weather 
and of climate. 

Excepting in the case of the extensive diffusion of the acute disease, 
eczema is rarely attended with constitutional symptoms. Locally it is 
characterized by the presence of more or less itching, tingling, or burn- 
ing. The itching in some cases, indeed, is unbearable. 

Treatment. — There is no specific treatment for eczema ; it is there- 
fore especially important in every case to ascertain if possible the cause 
on which it depends, or whether or not the patient have any associated 
malady affecting the general health ; and to treat it. Thus the con- 
stitutional treatment of eczema may resolve itself into the treatment 
of gout or indigestion; the local treatment into the destruction of in- 
sects, or the cessation from certain kinds of manual labor. Alkalies, 
such as liquor potassse or the bicarbonate of potash or soda, in combina- 
tion with vegetable tonics, are often resorted to. But the remedy on 
which most reliance is placed is arsenic. This is generally given in 
the same manner as in the treatment of psoriasis, and is by most physi- 
cians regarded as being most efficacious in the chronic forms of the 
disease. When febrile symptoms are present, mild laxatives and cooling 
medicines are desirable. Tonics are often beneficial in its later stages. 
It is well to pay attention to the diet. Alcoholic drinks are generally 
injurious, as also are rich foods and hot condiments. The local treat- 
ment must vary with the stage of the affection, its intensity, and its 
extent. In the acute stage, and always when there is much inflam- 
mation, cold-water dressings or evaporating lotions, or even the cold 
douche continued from ten minutes to half an hour at a time, are very 
useful. Under the same circumstances lead-wash, and such-like ap- 
plications, are beneficial. In later stages, when there is much accumu- 
lation of scabs, it is important to remove them either by washing with 
soft soap and water, or poulticing, or the saturation of the part with 
olive-oil. Then the surface must be kept clean ; and mild mercurial 
ointments, or ointments containing lead or zinc, may be gently applied 
after each washing. In the dry and scaly condition of eczema which 
simulates psoriasis, the treatment applicable to the latter affection may 
be employed. Hebra recommends for some cases the rubbing in of 
liquor potassse until it acts chemically on the diseased structures, for 
the purpose both of removing the morbid surface, and of promoting 
more healthy action. The caustic is applied once a week, the parts 
being treated with water-dressing in the intervals. Over limited arese 
of disease, the application of the solid nitrate of silver sometimes 
effects a cure. As a rule, however, we think that soothing local treat- 
ment, combined with cleanliness, will be found most efficacious. And 
although soap may be occasionally employed to aid in the removal of 
scabs, persistence in its use is generally injurious. The patient should 
use, instead of it, either bran, oatmeal, or starch, milk, or the yolk 
of egg. 



304 



DISEASES OF THE SKIN. 



IMPETIGO. {Ecthyma.) 

The affections comprised under these names are essentially pustular ; 
we regard them as being identical, and shall describe them as varieties 
of impetigo. 

Causation and Description. — Impetigo is a disease which consists 
in the formation of pustules at the surface of the skin, either between 
the cutis vera and the epidermis or between the corneous layer of the 
epidermis and the rete mucosum. The development of pustules is 
generally attended with more intense inflammation than the develop- 
ment of vesicles or papules ; and the pustules are, for the most part, 
surrounded by well-marked congested areola?, and are situated upon 
more or less distinctly thickened bases. They commence occasionally 
in vesicles or papules, and thus eczema or lichen may become converted 
into impetigo. Most commonly, however, they originate in spots of 
inflammation — stigmata, papules, or tubercles, in which suppuration is 
manifest almost from the beginning. The pustules vary in size from 
that of a pin's head (or less) to that of a split pea or bean. They are 
generally round or oval in outline, but sometimes irregular and angu- 
lar, and they project in the form of an oblate hemispheroid. At the 
end of a day or two they break, or their contents concrete, and scabs 
are formed, which are generally thicker and darker than those of 
eczema ; but which, nevertheless, vary very much in color and consist- 
ence, being sometimes softish, translucent, and honey-like, sometimes 
dark, opaque, and tough. If the progress of the pustules be favorable, 
the scabs separate after a few days, leaving reddish spots behind them, 
which are soon effaced by the completion of a normal layer of epi- 
dermis. Very often, however, the scabs become detached while the 
subjacent surface is still secreting pus; and not unfrequently, when the 
scab seems fully formed, suppuration still goes on beneath and around 
it, leading on the one hand to a deeper erosion of the skin, on the 
other hand to the lateral extension of the pustule by the gradual under- 
mining of the surrounding epidermis and the incorporation of the 
successive circles of suppuration thus formed. In these latter cases the 
local progress of the disease may be maintained for a long time ; and 
in these alone, but rarely even here, is there danger of the production 
of permanent cicatrices. The long continuance of impetigo leads 
sometimes to permanent harshness, muddiness, and deterioration of the 
skin. 

The lymphatic glands in relation with the part affected by the 
disease generally become inflamed, large, and tender, and occasionally 
suppurate. 

The pustules of impetigo sometimes come out singly {%. sparsa), 
sometimes in groups (i. figurata), and the groups may be of consider- 
able extent. In the former case the pustules are generally larger than 
those of the grouped variety, and if the subjacent thickening and the 
surrounding inflammation be considerable (as they are especially apt 
to be when the affection is seated on the buttocks or lower extremities, 
and in adults), the affection is often termed ecthyma. In the latter 



IMPETIGO. 



305 



case the congestion connected with the several adjoining pustules 
blends, and thus forms a common area of inflammation which is often 
very intense (i. erysipelatodes). The scabs also, under such circum- 
stances, run together and form a continuous mass or lamina {i. scabida). 

Impetigo occurs on all parts of the surface. It is common on the 
head and face, especially of young children, and when abundant and 
confluent in the latter situation is sometimes called porriyo larvalis. 
Occasionally it attacks the hairy parts of a man's face, and then con- 
stitutes one variety of the affection termed sycosis. It is then very 
intractable, owing probably to the fact that the root-sheaths of the 
hairs are specially involved. It is met with frequently about the but- 
tocks, and indeed on all parts of the trunk and extremities. 

Impetigo is very apt to spread by inoculation : thus it is conveyed 
from the child's head or face to the fingers with which it scratches 
itself; or from the nursling's face to the mother's bosom or hands j or, 
again, from child to child among the young members of a family or 
school. Sometimes it appears to originate idiopathically, and to be 
preceded by feverish symptoms, lasting for a day or two ; it may be a 
subsequent development of lichen ; and is very often produced by local 
irritation, arising from pediculi, acari, and even mechanical causes. It 
is common during the period of dentition. The duration of impetigo 
is very various, depending partly on the cause, partly on the health of 
the patient, and partly upon hygienic conditions. The acute form 
may subside at the end of a week or two; but the disease is very apt to 
be chronic, and kept up for months and even years by successive acute 
outbreaks. Those who have had previous attacks are liable to suffer 
from relapses. The constitutional symptoms are generally trivial ; 
there is often, however, some slight degree of fever when the affection 
is extensive and acute, especially if the lymphatic glands are implicated. 
There is generally some itching and tingling of the parts affected. 

Treatment. — The local treatment of impetigo differs but little from 
that of eczema. In quite the early stage the application of cold or 
tepid water, or cooling lotions, is useful. When scabs have formed it 
is always important to effect their removal, and this may be accom- 
plished in the same way as has been recommended with the like object 
in eczema. After their removal, the application of lead or zinc lotions, 
combined with glycerin, or of mild mercurial ointments, is generally 
sufficient. Caustics are rarely beneficial, or even admissible. When 
the hairy parts are affected it is always well' to have the hair cut short; 
and in the case of sycosis it is generally necessary to have recourse to 
epilation. As to general treatment, it is always important to treat any 
associated malady under which the patient is laboring, and which may 
be affecting his general health. It will generally, however, be found 
that tonics are the most suitable class of medicines, and especially iron 
in its different forms, mineral acids, quinine and other vegetable bitters, 
and cod liver oil. Change of air is often of great benefit. 



20 



306 



DISEASES OF THE SKIN. 



SUDAMIXA. MILIARIA. 

Description. — These names are employed to designate the minute 
vesicles which appear scattered over the surface of the chest, back, 
flanks, and sometimes upper arms and thighs of persons who are per- 
spiring profusely, or more frequently perhaps of those who, having had 
a dry skin for some time, commence again to perspire. Thus we meet 
with them in rheumatism, pneumonia, and in many fevers at the com- 
mencement of convalescence. They are believed to form at the orifices 
of the skin-glands, and to be due to the imprisonment of minute drops 
of sweat by the horny layer of the cuticle. They are generally no 
larger than a pin's head, round or irregular in shape, containing a 
colorless acid fluid, and quite unattended with inflammation. They 
can be easily felt as small, prominent, hard bodies ; but very often 
escape the eye unless carefully looked for, and then appear like minute 
drops of melted white wax. They end in branny desquamation. Oc- 
casionally their contents are opaline, and each vesicle is surrounded 
by a narrow halo of congestion. It is to sudamina presenting these 
latter characteristics that the term miliaria is sometimes, but unneces- 
sarily applied. No treatment is required. 



HERPES. PEMPHIGUS. 

Herpes and pemphigus are vesicular or bullous affections, yet there 
is a very close affinity between them and erythema, especially erythema 
multiforme ; and indeed it is questionable whether it might not have 
been best to discuss all these affections under the same heading. Both 
herpes and pemphigus become developed upon erythematous patches ; 
and not unfrequently these patches are papulate, discoid, circinate, 
gyrate, or marginate, and the vesicular or bullous eruption consequently 
assumes corresponding characters. Indeed, in no inconsiderable pro- 
portion of cases, erythema, herpes, and pemphigus simply represent 
successive stages of the same affection. Various causes have been 
assigned to herpes and pemphigus, and among them one which is of 
great interest, namely, some affection, probably irritative, of the sensory 
nerves. One form of herpes — herpes zoster — is, as we shall presently 
show, always limited to the area of distribution of some one or more 
of the nerves of common sensation, and usually attended with intense 
neuralgic pain ; and, moreover, erythematous, vesicular, and bullous 
eruptions are shown by various authors, and especially by Charcot, to 
be common accompaniments of pachymeningitis of the cord and of other 
conditions causing equivalent irritative effects in the cord or nerves 
connected with it. 

Herpes. 

Causation and Description. — By this term we understand an affection 
characterized by the appearance of clusters of vesicles, varying each 



HERPES. 



307 



between the size of a small pin's head and that of a split pea, and 
seated on an erythematous base. In the process of development a cir- 
cumscribed area of redness, round, oval or irregular in shape, makes its 
appearance. This soon becomes studded thickly with papules, which 
speedily acquire a vesicular character, and in the course of twenty- 
four hours or less attain their full dimensions. The vesicles are very 
close-set, and not unfrequently run more or less together — sometimes, 
indeed, by this means forming large bullae. The contents are in the 
first instance limpid and pale ; they often, however, become dark from 
admixture with blood, or opaque and yellow in consequence of suppura- 
tion. After two or three days they begin to dry up, and then form 
thinnish dark-colored or gummy scabs, which after a few days become 
detached, leaving a whole but slightly reddened surface behind. There 
is always much heat and tingling or stinging during the earlier stages 
of the disease. The total duration of herpes is rarely more than two 
or three weeks, and often considerably less. 

Several forms of herpes are enumerated by dermatologists. We pro- 
ceed to discuss the more important of them : 

1. Zona or Herpes Zoster (Shingles). — This is the most important and 
striking affection of the group. It is characterized by the formation of 
clusters of vesicles on inflamed patches of various forms, and ranging 
from the size of the palm of the hand to that perhaps of a split pea. 
The clusters appear almost simultaneously, and irregularly scattered 
over the area of distribution of one of the cutaneous sensory nerves. 
They hence always occur within certain definite limits and on one side of 
the body only. In addition to the general characters of herpetic affec- 
tions, zona is attended with certain special peculiarities. Thus it is 
very often accompanied with severe neuralgic pains in the neighborhood 
of the part affected, which sometimes precede, sometimes accompany, 
and sometimes follow the cutaneous eruption, and often last for many 
weeks; and, again, the inflammation is apt to be intense and to pene- 
trate deeply, and hence to be slow of disappearance and to leave per- 
manent scars, and sometimes (in the old and weakly especially) to 
become gangrenous. 

The most frequent seat of zona is the chest or abdomen, where it 
takes the course of the cutaneous branches of one of the intercostal 
nerves. But it is not uncommon elsewhere, though it is very often not 
then recognized as zona. Von Barensprung enumerates nine varieties ; 
and it would be possible, but is not necessary, to enlarge their number ; 
they are as follows : z. facialis, where the parts supplied by the fifth 
pair are affected, the surface of the conjunctiva being sometimes in- 
volved; z. occipito- collar is, following the distribution of the occipitalis 
minor, auricularis magnus, superficialis colli, and occipitalis major; 
z. cerv ico-sub clavicular is, corresponding to the descending superficial 
branches of the cervical plexus (supra-sternal, supra-clavicular, and 
supra-acromian) ; z. cervico-brachialis, affecting surfaces supplied by 
branches of the brachial plexus; namely, the shoulder, upper arm, 
forearm, and even hand; z. dorso-pectoralis, corresponding to the third, 
fourth, fifth, sixth, and seventh dorsal nerves; z. dorso-abdominalis, 
corresponding to the eighth, ninth, tenth, eleventh, and twelfth dorsal 



308 



DISEASES OF THE SKIN. 



nerves ; z. lumbo-inguinalis, corresponding to the branches of the upper 
lumbar nerves, extending from the loin to the linea alba, and involv- 
ing also the pubes and genital organs, the gluteal region and outer 
aspect of the thigh ; z. lumbo-femoralis, corresponding mainly to the 
cutaneous branches of the second, third, and fourth lumbar nerves, 
more especially the external cutaneous, genito-crural, anterior-crural, 
and obturator, and affecting therefore mainly the anterior and lateral 
surfaces of the thigh and the inner aspect of the leg and foot ; and 
lastly, z. sacro-ischiaticus, which follows the cutaneous branches of the 
sacral plexus. 

Zona attacks persons of all ages, but chiefly, it is said, young adults. 
It is held by some to be most common in spring and autumn, and also 
to occur only once in a lifetime. It is questionable, however, whether 
either of these statements is true. Its connection with nervous irrita- 
tion has been already referred to; but nothing more in reference to its 
causation is known. 

2. Herpes Simplex. — This name may be conveniently used of those 
cases in which a group of vesicles or several such groups appear almost 
suddenly in some limited area, which then gives a specific name to the 
affection. Thus we have h. labialis, affecting the lips and neighboring 
parts; h. palpebralis, affecting the eyelids; h. auricular is, affecting the 
pinna of the ear; and h. prceputialis and pudendalis, affecting respec- 
tively the prepuce and the labia. In these cases the patches of disease 
are identical in appearance and progress with those of zona. But there 
is nothing to indicate that they have any connection with sensory nerves. 
Moreover some of them (especially h. labialis) are especially apt to 
attend an ordinary catarrh, and to supervene in the course of acute 
pneumonia. 

3. Herpes iris is the name given to an eruption of vesicles which 
arise in series of concentric, rings upon a gradually enlarging erythema- 
tous disk. It is most frequently observed on the backs of the hands 
and wrists, feet and ankles, but is sometimes much more generally dis- 
tributed. 

4. Herpes circinatus is the name applied to an inflamed disk, which 
gradually increases in size, and whose enlargement is marked by the 
formation of a ring of vesicles at the circumference, while the centre 
for the most part gradually returns to a state of health. 

It is obvious, as we have already pointed out, that there is no essen- 
tial difference between these latter two varieties or between them and 
erythema multiforme; and that herpes iris and herpes circinatus are 
simply later phases of erythema iris and erythema circinatum. It may 
be added that intermediate papular conditions are sometimes observed, 
to which the names of lichen iris and lichen circinatus might (unneces- 
sarily indeed) be applied. 

It is important, however, to bear in mind that the name " herpes 
circinatus" is often given to the specific eruptions of tinea favus and 
tinea tonsurans, and that indeed the multiform erythematous and vesic- 
ular affections which have just been considered (although not them- 
selves parasitic) are very apt indeed to be simulated by and confounded 
with these vegetable parasitic diseases. 



PEMPHIGUS. 



309 



Lastly, we may point out that cases are occasionally observed in 
which erythematous patches, irregular in form and size, appear almost 
simultaneously over the whole cutaneous surface, and become speedily 
covered with herpetic vesicles which tend to run together. The patches 
indeed are like those of herpes zoster, but differ from them in their 
wide distribution; and, moreover, like herpetic patches generally, run 
through all their stages in the course of a week or two. 

Herpes iris, h. circinatus, and the form of herpes last described, re- 
semble in their symptoms the corresponding forms of erythema mul- 
tiforme. They are usually of trivial importance, but occasionally, when 
of extensive distribution, are attended with much febrile disturbance. 

Treatment. — Whatever its form may be, herpes rarely requires special 
treatment. Cooling lotions, simple ointments, and means to prevent 
the affected parts from being rubbed, include all the local measures that 
are usually necessary. The only important object to aim at in the treat- 
ment of zona is the relief of the severe neuralgic pain which is so often 
associated with it. For this various measures may be tried, such as the 
local application of blisters or other counter-irritants, the inunction of 
belladonna, or, still better, of aconitia ointment, or the use of leeches; 
and, besides these, morphia or other sedatives administered by the 
mouth or hypodermically. 

Pemphigus. 

Causation and Description. — This term comprises most of those in- 
flammatory affections of the skin which are attended with the formation 
of bullae or blebs. These sometimes attain the size of a hen's or duck's 
egg, and are developed on round, oval, sinuous, or irregular surfaces. 
But associated with such blebs we frequently find single or grouped 
vesicles no larger tljan those of herpes. Hence the blebs of pemphigus 
may be considered to vary between these limits. There is nothing 
specific, however, in the formation of a bleb ; any patch of erythema, or 
of other form of inflammation, or of gangrene, may become studded with 
vesicles, and any number of contiguous vesicles may run together so as 
to form a common cavity. It follows almost necessarily that there is 
nothing specfic in the conditions to which the term pemphigus is ap- 
plied, and that the limits between them and affections receiving other 
names are to a great extent arbitrary. 

Pemphigus is not unfrequently (as has been pointed out above) the 
fully developed stage of herpes iris, herpes circinatus, and the other 
forms of generally distributed herpes which we have described. The 
stages of the disease are then well marked, — the first being the appear- 
ance of a disk or ring or irregular patch of erythema ; the second the 
formation of small vesicles, sometimes in a ring at the circumference, 
sometimes in the centre, sometimes generally over the surface ; and the 
third the extension or the blending of these vesicles and the evolution 
of a prominent bulla, the edges of which become, for the most part, 
conterminous with those of the erythematous redness. Owing to the 
coalescence of neighboring patches of erythema, neighboring bullas may 
coalesce into sinuous or gyrate bullous bands several inches in length. 



310 



DISEASES OP THE SKIN. 



Further, the eruption may be sparse or limited in extent, or it may be 
general and abundant. The full development of the disease may occupy 
three or four days, or more, but is often much more rapid. In cases 
of this kind it sometimes happens that extensive tracts of surface be- 
come erythematous and remain so for some time, vesicles and bullae 
appearing here and there from time to time upon them. In other cases 
of pemphigus, the formation of the bulla? is almost coetaneous with the 
appearance of the erythema, which may then indeed escape recognition 
as a separate stage of the affection, both being preceded by violent 
itching, stinging or burning. The bulla? of pemphigus are generally 
plump and distended with a pale straw-colored serum, which, after 
awhile, becomes darker colored or milky and opalescent. After a few 
days the fluid begins to disappear by evaporation and absorption, or the 
bulla? become ruptured and the fluid escapes. Then a thin dry pellicle, 
consisting of the epidermis which had been raised up and of coagulated 
exudation, forms upon the affected surface, and after a few days more 
becomes detached, leaving a sound but somewhat reddened area behind. 
Sometimes, especially if the part have been irritated by scratching or 
otherwise, or if the general health of the patient be bad, the scab more 
resembles that of eczema or even impetigo, probably re-forms after re- 
moval, and convalescence may become very much protracted. Ulcera- 
tion or even gangrene may ensue. 

As will be gathered from the foregoing account, pemphigus presents 
a good many varieties. Sometimes it is acute, its entire duration being 
comprised within a period of three or four weeks. More frequently it 
is chronic — chronic, however, in the sense in which urticaria evanida is 
chronic — that is, prolonged by successions of acute attacks. It is then 
often termed p. vulgaris. Sometimes a single bulla breaks out suddenly, 
to be followed on its subsidence by a second, and then by a third, and 
so on (p. solitarius). A form of the disease, termed p. infantilis, is oc- 
casionally met with in newly born children ; large bulla? form on the 
neck, behind the ears, on the buttocks, genitals, wrists, and other parts, 
and for the most part progress unfavorably, ending in suppuration, 
ulceration, and gangrene. A further variety is that termed by Alibert 
p. foliaceus. It is characterized by the successive formation of bulla? 
of small size, which are generally flat and flaccid, and the contents of 
which become more or less distinctly purulent, and dry up into thick 
yellow flaky scabs. These on separation leave a deeply congested weep- 
ing surface. P. foliaceus is said to spread gradually until it occupies 
the entire surface of the body, and never to be cured. 

The causes of pemphigus are not clearly known. There is reason, 
however, to believe that in some cases, especially in that of p. infantilis 
or when it occurs on the soles or palms, the origin is syphilitic. And, 
as we have already pointed out, it appears in some instances to be con- 
nected with affections of the spinal cord or sensory nerves. The symp- 
toms which attend its progress vary. There is often some degree of 
fever; sometimes high fever; and, when the affection is much pro- 
longed, debility and emaciation may ensue. This latter is especially 
the case in the foliaceous form. Newly born children affected with 
pemphigus generally succumb speedily. In many cases the patient's 



RUPIA. 



311 



health remains apparently unimpaired throughout the whole duration 
of the malady. 

Treatment — The bullae require little local treatment. They may be 
punctured and their contents permitted to escape ; but it is unadvisable 
to allow the cuticular pellicles covering them to be detached. For this 
reason, among others, it may be necessary to protect the parts with 
simple ointments spread out on lint. For internal treatment iodide of 
potassium and mercurial preparations should be employed when syph- 
ilis is suspected. Arsenic is much lauded by some. In most cases, 
however, tonics are sooner or later indicated. 



RUPIA. 

Causation and Description. — This is a disease which is described as 
beginning with flat bullae, rarely, if ever, exceeding half an inch in 
diameter; first containing clear serum, then producing very thick 
greenish-brown or dark-colored scabs, and deep destructive ulceration. 
In some respects, therefore, the disease resembles pemphigus ; it differs, 
however, from all ordinary forms of pemphigus in the fact that its 
bullae are the result, not of superficial, but of deepseated disease. 
Rupia, indeed, is to be distinguished, not so much by the fact that it 
is a bullous disease, as by the character of its post-bullous stages. The 
rupial bulla slowly increases in size, is surrounded by a halo of con- 
gestion, and seated on a very slightly thickened base. A scab very 
soon forms, but while it is forming the bulla spreads at its margins, 
and fresh matter, which also soon coagulates, is produced around and 
under the first formed scab. In this way the rupial sore increases in 
diameter, the scab increases in thickness and prominence, and the sub- 
jacent ulcer becomes deeper and deeper. The resulting scab is always 
very thick, but sometimes flat and flaky, something like an oyster- 
shell (r. simplex), sometimes conical, like a limpet-shell (r. prominens), 
sometimes irregular and rocky in form. On its removal, a fresh scab 
usually forms. The ulcers beneath such scabs are always deep and 
unhealthy-looking, and cause much destruction of tissue and perma- 
nent cicatrices. In some cases, those of children especially, the ulcer- 
ation extends rapidly, presenting a phagedenic character (r. escharotica), 
or becomes distinctly gangrenous, when it is sometimes termed pem- 
phigus gangramosus. Rupial sores are generally scattered and few in 
number, and are not limited to any particular part of the person. 
They are, perhaps, most common on the buttocks and lower extremities. 

Rupia rarely, if ever, happens in persons w T ho are not obviously 
weakly and cachectic, and most frequently in those who have previously 
had syphilis. Indeed, there is some reason for regarding true rupia as 
essentially a syphilitic disease. 

Treatment. — In the constitutional treatment of rupia, tonics of va- 
rious kinds, iron, mineral acids, vegetable bitters, cod-liver oil, together 
with good diet and change of air, are all-important. Anti-venereal 



312 



DISEASES OF THE SKIN. 



remedies must not, however, be forgotten, especially if there be a clear 
syphilitic history. For local treatment, poultices are necessary to aid 
in the detachment of the scabs; and the resulting ulcers must be 
treated not only with poultices but with stimulating or detergent oint- 
ments or washes, and even in some cases with undiluted caustics, such 
as nitrate of silver, nitric acid, acid nitrate of mercury, or other such 
agents. 



INFLAMMATION OF THE SEBACEOUS GLANDS. ACNE. 

By the term acne is meant an inflammatory affection of the seba- 
ceous glands, dependent on, or at all events connected with, retention, 
in them of their secretory products. In most inflammations of the 
skin the sebaceous glands of the part affected share in that inflamma- 
tion ; and always in acne there is more or less tendency for inflamma- 
tion to extend from the sebaceous glands to the contiguous structures. 
Hence, as might be expected, acne occasionally and especially in some 
of its forms passes into other recognized varieties of inflammation of 
the skin. Further, inflammation of the sebaceous glands is sometimes 
attended, not with retention of secretion, but with increased production 
and flow, so that we may have an inflammation involving the sebav 
ceous glands which is not acne. This is sometimes named seborrhoea. 

Seborrhosa. 

Causation and Description. — The secretion of sebum is naturally in 
some persons exceedingly profuse, but it is not therefore morbid, and is 
only seriously inconvenient in the absence of scrupulous personal clean- 
liness. In some cases, however, an excessive production of sebum oc- 
curs over certain limited arese, attended with distinct hyperemia of the 
parts, and more or less obvious hypertrophy of the glands. Indeed, the 
increased production is limited to patches of distinct erythema. This 
affection is not unfrequent in the scalp and on the face, especially in 
children. The secretion is most frequently more solid than sebum 
should be, and with the superficial epidermis concretes into greasy 
flakes, which adhere to the surface. A condition is thus produced 
which differs little and not essentially from pityriasis of the same parts. 
More rarely the secretion of the glands is quite fluid, and may be seen, 
after cleansing the surface, to form minute drops at each glandular 
orifice. This condition, which is occasionally observed on the cheeks 
and nose, is apt to be very chronic, and sometimes becomes permanent. 

In the treatment of these affections plentiful ablution with soap and 
water, and the use of astringent lotions, containing acetate of lead or 
sulphate of zinc, or of mercurial preparations, are the chief measures 
to be employed. Constitutional treatment is generally useless. 

Acne. 

Causation and Description. — The unnatural accumulation of seba- 



INFLAMMATION OF THE SEBACEOUS GLANDS. 



313 



ceons matter within the sebaceous glands is of extremely common oc- 
currence. It may be met with in glands whose orifices are still patent, 
as well as in those whose mouths are obliterated. In the former case, 
the orifices are dilated and prominent, and occupied by the dirt-black- 
ened superficial portions of the accumulated sebum, the whole of which, 
by squeezing, may be removed in the form of small, maggot-like 
bodies (comedines). In the latter case no orifices are generally detecta- 
ble, the sebum retains its normal yellowish hue, and concretes into 
hard, pearly, laminated masses. This condition was termed by Willan 
strophulus albidus. A small incision is generally necessary for their 
removal. Sebaceous tumors or wens differ little except in size and in 
the consistence of their contents from the bodies last named. 

When such accumulations of sebum are associated with inflammation 
of the parts immediately surrounding them, we have that condition 
present to which the term acne is generally applied. Acne, therefore, 
may occur in two forms. In the one there is circumscribed inflam- 
mation, attended with induration, prominence, and duskiness of tint, 
but the cause of inflammation is rendered obvious by the fact that at 
the most prominent point of the resulting tubercle there is a dilated 
sebaceous orifice, choked with the secretion of the gland. In the other 
case, the orifice of the gland is undistinguishable, the accumulation 
is deepseated, inflammatory products are effused around, beneath, and 
superficial to it, and thus an indurated congested prominent tubercle 
is produced, which yields on inspection no visible proof of its connec- 
tion with sebaceous accumulation. The tubercles of acne vary much 
in size, and are sometimes as large as a horse-bean. They often sup- 
purate, but, especially in the latter form, suppurate very slowly, lead- 
ing before they discharge their contents to a good deal of localized dis- 
organization, and eventually to the production of permanent scars. 
Their contents are scanty but thick, and consist partly of sebaceous 
matter, partly of pus. 

Different forms of acne are described, of which the majority are 
mere varieties of the same condition, and are generally combined in 
various proportions in the same case. The term acne punctata is often 
applied to that very common condition in which the sebum simply 
accumulates in the follicles, and leads by its accumulation to the pro- 
duction of a series of black-tipped papules. By acne simplex is gener- 
ally understood acne punctata associated with inflammation and suppu- 
ration — the papules being surrounded by congestion, and often going 
on to the formation of small superficial abscesses, which in a short 
time discharge their contents, and after a few days, or a week or two, 
heal up. The name acne indurata is given to those cases which are 
marked by general enlargement or induration with dusky or livid dis- 
coloration, and slow deepseated suppuration. It must be added here 
that one form of sycosis is distinctly an acne indurata of the hairy re- 
gions of the face. 

Any part in which sebaceous glands exist may be the seat of acne. 
Acne, however, is most common on the face, especially the forehead, 
cheeks, nose, and chin ; and on the trunk, mainly between the shoulders 
and on the chest. 



314 



DISEASES OF THE SKIN. 



It rarely occurs in young children, excepting in the form of stroph- 
ulus albidus ; it is most common in both sexes about the period of pu- 
berty, and from that time onwards to two or three and twenty. It 
is frequently met with, however, and then especially in its indurated 
form, in persons of middle and even of advanced age. 

The causes of acne are obscure. It is certain, however, that the 
tendency to the affection runs in families, and has a special connection 
with the period of development and maturation of the sexual functions. 

Treatment. — In treating acne, it is of great importance to insist on 
frequent and thorough washing with soap and warm water, to be fol- 
lowed by the friction of a rough soft towel, or of a flesh-brush. These 
measures, however, are even more important to prevent than to cure. 
All black spots should be removed either by squeezing the papules in 
which they are contained between the nails, or by pressing down upon 
them a ring, a little larger than the black spot, and including it. The 
mouth of a watch-key answers the purpose very well. Superficial col- 
lections of matter should be punctured, and discharged. The chronic 
tubercles of acne indurata should be opened with a narrow-bladed 
knife, and have their contents expressed, or should be touched at the 
summit with the acid nitrate of mercury, or some other equivalent 
escharotic. The local inflammation may be allayed to some extent by 
the use of lead-wash, or lotions containing from two to four grains of 
sulphate of zinc, or from half a grain to two, three, or even four grains 
of bichloride of mercury to the ounce. Mild mercurial ointments are 
sometimes useful. Sulphur, in the form of ointment or lotion, is strongly 
recommended by most dermatologists. In our general treatment we 
can aim only at improving the general health, and must be guided, 
therefore, solely by the general symptoms which the patient presents. 

In sycosis it is important to have the hair of the affected parts kept 
closely cut, and to remove the hairs running through the tubercles or 
pustules by frequently repeated epilation. Hebra insists on the ne- 
cessity for keeping the surface constantly shorn, for the application of 
sulphur and other stimulating ointments, and for the incision of the 
inflamed tubercles. 

Acne Rosacea. 

Causation and Description. — The condition to which this name is 
commonly given has been regarded by most modern authors as a mere 
variety of acne. Hebra, however, maintains that it is essentially dis- 
tinct from acne, although very frequently indeed associated with it. 
There is no doubt that it consists generally in more or less extensive 
patches of inflammatory redness, associated with slight infiltration of 
the affected cutis and visible dilatation of the superficial vessels, and 
also with the presence here and there upon the inflamed patches and 
in their neighborhood of tubercles corresponding precisely to the 
description already given of those of acne indurata. The affection, 
therefore, is really an inflammatory condition of certain parts of the 
skin, in which there is a special tendency to include the sebaceous 
glands. Acne rosacea is limited to the face, affecting sometimes the 
nose, sometimes the cheeks, sometimes the forehead, sometimes the 



INFLAMMATION OF THE SEBACEOUS GLANDS. 315 



chin, but generally several of these regions at the same time. It is for 
the most part symmetrical in its distribution, and tends gradually to 
extend. It usually commences with circumscribed hyperemia of the 
nose or cheeks, attended often with an increased secretion of sebaceous 
matter, and generally with a more or less obvious development of 
dusky-red tubercles, which may or may not suppurate. This con- 
dition, variable at first, soon becomes permanent, the cutis getting 
infiltrated and thickened, the small veins of the part dilated and tor- 
tuous, the formation of tubercles more abundant, and the face greatly 
disfigured. In this latter condition the disease may remain for many 
years, and even for life, without any material change. But in some 
cases, and more especially in those of elderly men who have been ad- 
dicted to excess in alcoholic drinks, the affection, which is then almost 
invariably limited to the nose and its immediate neighborhood, assumes 
a hypertrophic character; the parts which were originally affected 
with a simple form of acne rosacea become swollen and tuberculated, 
until in some instances the nose forms a huge misshapen, lobulated, 
pendulous mass. These changes are due to inflammatory hyperplasia 
of the cutis vera, the tissues subjacent thereto being rarely, if ever, 
implicated. The sebaceous glands, however, are involved and hyper- 
trophied, sometimes still discharging their products through the yet 
patent ducts, sometimes from obstruction, forming accumulations of 
sebum, and, it may be, undergoing suppuration. The affected parts 
become deeply congested, and the dilated varicose veins larger and 
more numerous. 

Beyond the heat and flushing, which are liable to frequent exacer- 
bations, little local inconvenience or discomfort attends the various 
forms of acne rosacea. 

Acne rosacea, in its simpler variety, is an affection of adult life, 
coming on generally between 25 and 30, but sometimes making its 
appearance for the first time as late as 40 or upwards. It is far more 
common in women than in men. The hypertrophic variety of the 
disease, on the other hand, is rarely observed in women, and it attacks 
the opposite sex for the most part in middle age or the decline of life. 
The causes of hypertrophic acne rosacea are not in all cases obvious ; 
there is no doubt, however, that in a large proportion it is traceable to 
long-continued habits of intemperance or over-indulgence in spirituous 
liquors. The difficulty of assigning a cause to the other form of this 
affection is still greater ; nevertheless, it is certain that many of those 
who suffer from it are dyspeptic or liable to uterine disturbances, and 
that when any of these complications are temporarily present there is 
almost invariably marked exacerbation of the facial inflammation. 

The treatment of acne rosacea differs little from that of simple acne. 
It is especially important here to attend to the general health and 
habits of the patient, to remedy indigestion, to remove anaemia, to 
prescribe a wholesome unstimulating diet, and to maintain the healthy 
functions of the skin and other organs. The local treatment is abso- 
lutely that of acne simplex; it will generally need, however, more 
persistent employment. 



316 



DISEASES OF THE SKIN. 



i 



LUPUS. (Noli me tangere.) 

Causation and Description. — The term "lupus" is applied to a series 
of affections, characterized by a specific overgrowth of the cutis, for 
the most part of chronic progress, and resulting in the formation of 
indelible cicatrices, or in more or less extensive destruction of tissue. 

Lupus usually commences with more or less distinct congestion and 
hypertrophy of a limited area, which, in a large proportion of cases, 
is studded with solitary or grouped lenticular tubercles a line or two 
in diameter, and presenting a slightly translucent aspect and a dull 
red or a pale salmon color. The patch of congestion slowly increases 
in area or the tubercles in number, until in many cases a large extent 
of surface becomes after awhile involved. While this extension is in 
progress various changes take place. In some instances the parts first 
implicated, without attaining any further stage of development, grad- 
ually lose their inflamed and hypertrophic character, but instead of 
simply reverting to the healthy condition, become pale, depressed, and 
contracted, and assume a cicatricial character. In some instances pre- 
vious to the attainment of this cicatricial termination, they become 
covered with thin adherent scales, or with thick crusts. In some the 
tubercles, almost from the beginning, are the seat of suppuration, and 
become crowned with thick adherent scabs. In some extensive ulcer- 
ation ensues, with grievous and irremediable destruction of parts. In 
its morbid anatomy lupus appears to consist in the development of a 
kind of tissue, resembling granulation-tissue, composed of small cells, 
imbedded, according to the density of the growth, in a greater or 
smaller quantity of fibrous material. Lupus is generally regarded as 
a scrofulous disease ; and it not unfrequently occurs in those who are 
suffering or have suffered from scrofulous suppuration of the cervical 
glands, or who are otherwise out of health ; moreover exacerbations 
of the disease seem not unfrequently to be induced in those who are 
already its subjects, by temporary conditions of general ill health. 
Females suffer from lupus much more frequently than males, children 
than adults, and the poor than the well-to-do. The local symptoms 
which attend its progress are for the most part trivial ; often the pa- 
tient makes no complaint, or, if he complains at all, complains only of 
itching or tingling. 

In accordance with the different peculiarities of character and prog- 
ress which have been above referred to, several varieties of lupus 
have been described, the more important of which we shall now briefly 
discuss. 

1. Lupus Erythematosus. — This form of lupus, which was first de- 
scribed and named by Alibert, is the least severe form of the disease. 
It occurs mainly on the cheeks, nose, forehead, or scalp, but is not 
limited to these parts ; and it makes its appearance there in the form 
of rounded erythematous patches, which slowly increase in diameter, 
and may readily be at first mistaken for patches of simple erythema. 
But they become sooner or later covered either with thin scales, or with 
crusts of considerable thickness, composed largely of sebaceous matter, 



LUPUS. 



317 



and continuous by their under surfaces with processes of the same ma- 
terial prolonged into the dilated orifices of the subjacent sebaceous 
glands. In the former case the affection simulates psoriasis; in the 
latter that morbid condition of the knuckles caused by dissection, to 
which Dr. Wilks has given the name of verruca necrogenica. The 
progress of lupus erythematosus is very chronic, and is scarcely attended 
with any abnormal sensations, but when it subsides it leaves behind it 
permanent changes in the condition of the skin. It commences usually 
in adult life and affects women more commonly than men. 

2. Lupus Exedens and Non-exedens ( Tubercular Lupus). — Lupus non- 
exedens, like the last, may occur on any part of the surface of the 
body, but usually originates on the nose or cheek. It commences with 
the appearance of small tubercles, such as have been above described; 
which slowly increase in number, sometimes assuming an annular 
arrangement ; which involve more and more of the contiguous cuta- 
neous surface, and sometimes indeed extend to the mucous membrane, 
and especially to that of the nose. Their course is very variable. 
Sometimes, after making but little progress, they slowly subside. 
More frequently they advance irregularly, now remaining quiescent 
for awhile, now undergoing comparatively rapid extension, and thus, 
continuing for years, ultimately involve extensive tracts of skin. 
These become seamed and puckered, and of a grayish white color in 
those parts which have undergone involution, and present groups of 
reddish tubercles in those which are still extending. In the progress 
of tubercular lupus, the tubercles not unfrequently become covered 
with scales or crusts, below which gradual erosion is going on, or they 
undergo actual suppuration or ulceration with the formation of scabs. 
In some cases the tendency to suppurate or ulcerate, and to scab, forms 
a special feature in the disease, which then receives the name of lupus 
exedens. This leads to more or less rapid and extensive destruction of 
tissue, and when occurring (as it most frequently does) in connection 
with the nose, not uncommonly involves the gradual removal of more 
or less of the septum nasi and of the cartilages which bound the nostrils. 
The cicatrization to which lupus non-exedens, and still more that to 
which the exedent form leads, is not merely in a high degree dis- 
figuring, but often induces serious consequences. The eyelids become 
retracted, the nose curiously thin and pointed, the ala? contracted and 
the nostrils altered in shape, the mouth distorted, the lower lip and 
chin drawn down upon the chest, as they may be after extensive burns. 
The forms of lupus here described usually commence in early life, but 
are frequently prolonged by successive outbreaks up to an advanced age. 

3. Pustular Lupus. — This variety of the disease simulates impetigo. 
It is sometimes limited to the face, and has then been termed by Mr. 
Startin impetiginous lupus. Sometimes, however, the whole surface — 
head, face, trunk, limbs — becomes more or less thickly covered with it. 
The eruption consists of tubercles, which are mostly discrete, but here 
and there collected into confluent patches, which vary from J to ^ inch 
in diameter, tend to suppurate scantily at their most prominent points, 
and presently become crowned with small dark, hard scabs, deeply 
imbedded, and remaining fixed (unless detached by violence) for weeks 



318 



DISEASES OF THE SKIN. 



or months. The detachment of one scab is liable to be followed by 
the formation of another ; but sooner or later each tubercle becomes 
absorbed, leaving behind it a temporary livid discoloration and a per- 
manent depressed cicatrix. Pustular lupus is often associated with the 
presence of suppurating scrofulous glands. 

Treatment. — In the treatment of lupus, constitutional remedies hold 
an important place. Among these, the most efficacious are cod-liver 
oil, quinine, iron, and other forms of vegetable and mineral tonics, and 
arsenic. If there be a suspicion of syphilis (and it is often extremely 
difficult to distinguish non-specific lupus from some forms of tubercular 
syphilide), the ordinary antisyphilitic remedies must not be omitted. 
Change of air is often valuable. Local remedies are very variable in 
their effects. Sometimes they seem to do more harm than good, some- 
times their use appears to be followed by rapid amendment. In the 
tubercular form of the disease, especially if the tubercles be attended 
with ulceration or any other form of destructive process, the use of the 
solid nitrate of silver, or of the potassa fusa, or of the acid nitrate of 
mercury, or of arsenical paste (made according to Mr. Startin's for- 
mula, with three parts of arsenious acid, two parts of bisnlphuret of 
mercury, and one part of calomel, together with water), is often useful. 
The caustic, however, needs to be repeated from time to time, and pre- 
vious to its application the surface should be freed from scales and 
scabs. In the milder cases less severe local applications are usually in- 
dicated, — nitric acid lotions, iodine paint, blistering fluids, mercurial, 
lead, or zinc ointments, or other such preparations. 



KELOID. {Kelts.) 

Causation and Description. — This is a peculiar affection of the skin, 
first described and named by Alibert. It is characterized by the 
gradual formation of roundish, elongated, linear or irregular, and, it 
may be, reticulate patches, which are elevated a liue or two, or even j 
much more than that, above the general level of the skin, and appear 
to be due to a hypertrophic condition of the cutis. The patches vary 
in color, but are usually either white and shining, or of a more or less 
rosy hue, and often marked with obvious vascular ramifications. They 
are for the most part smooth and rounded in the vertical direction, and 
are especially characterized by sending out claw-like processes or spurs 
here and there, which gradually lose themselves in the surrounding 
healthy skin. It is from this peculiarity that their name was derived, 
and that they acquire their generally recognized resemblance to hyper- 
trophic scars. They are dense and firm in consistence, and never be- 
come covered with scales or crusts, or undergo ulceration or other such 
destructive changes. They are sometimes attended with tingling, itch- 
ing, or burning, and are often tender to pressure. Their progress is 
slow, and they usually extend for a time gradually, and then not un- 
frequently become stationary, but occasionally they undergo involution 



XANTHOMA. 



319 



and disappear. In the early stages of their development they con- 
sist largely of fusiform cells, and are by Virchow and others regarded 
as sarcomatous. At a later stage they become almost entirely fibrous. 

Keloid commonly occurs in isolated patches of various sizes on the 
chest or back ; it may, however, be multiple, and it may be met with 
on any part of the surface, even the face, the ears, the genital organs, 
and the extremities. Occasionally it involves nearly the whole of the 
trunk. 

The causes of the disease have not been clearly determined. It 
occurs, however, mainly in adults, and seems not unfrequently to be 
induced by local irritation or injury. And indeed, one form of it, 
which is generally termed false keloid, seems to be clearly due to hy- 
pertrophic changes occurring in connection with ordinary scars. 

The treatment of the disease is unsatisfactory. The growths, when 
large, have occasionally been removed with the knife, but the results 
have not been encouraging. Local applications, such as iodine paint, 
blistering fluid, and various forms of stimulating ointments, have been 
tried and recommended, but, again, the benefit resulting from them 
has rarely been very decided. 



XANTHOMA. ( Vitiligoidea. Xanthelasma.) 

Causation and Description. — This affection was first clearly described 
by Drs. Addison and Gull under the second of the names given above. 
It has since been carefully investigated and described by various der- 
matologists, and more especially by Dr. Hilton Fagge. It consists 
mainly in a kind of fatty or atheromatous change in the texture of 
certain portions of the skin, and in this respect has a very close affinity 
to atheroma of the arteries. The affected parts appear on section to 
consist of fibrous tissue (in a greater or less degree the normal fibrous 
tissue of the part), studded more or less abundantly with groups of oil- 
globules. It occurs in two forms, namely, xanthoma planum, and x. 
tuberosum. In the former the affected portions of skin present an 
opaque, yellow, or buff color, are distinctly marginated, and although 
perhaps appearing to be elevated, are actually level with the general 
cutaneous surface, and undistinguishable from it in consistence and 
texture. In the latter variety papules or tubera arise, varying from 
the size of a pin's head to that of a hazelnut, which sometimes by their 
aggregation form nodulated masses of considerable extent. These are 
generally yielding and elastic, and but little indurated, are of the nor- 
mal color of the skin, or of a reddish hue, and frequently studded, 
especially in their more prominent parts, with opaque yellow spots. 
Xanthoma is often unattended with local uneasiness ; in the tubercular 
form, however, there is not unfrequently some degree of itching or 
tingling, and tenderness. Its course is for the most part progressive, 
but sometimes it becomes stationary, and occasionally disappears. It 
never undergoes ulceration or other such destructive change. 



320 



DISEASES OP THE SKIN. 



Xanthoma may occur on almost any part of the surface; on the 
eyelids, the nose, the ears, the cheeks, the head, the neck, on the shoul- 
ders and nates, on the back of the elbows, the front of the knees, about 
the wrists and ankles, on the palms and soles, and on the knuckles of 
the fingers and toes. When occurring in the neighborhood of joints 
the affection seems to be not unfrequently distinctly connected with the 
tendons, Xanthoma has also been observed in the mucous membrane 
of the nose, gums, lips, tongue, and larynx. The plane form of the 
disease is met with mainly in connection with the eyelids, ears, and 
other parts of the face and the mucous membranes. This, if the affec- 
tion be at all largely distributed, occurs concurrently with the tuberose 
form ; but it is not unfrequently alone present and limited to the face 
and more particularly to the eyelids. In the latter case it usually 
commences in the skin of the upper lid near the internal canthus, and 
not unfrequently gradually extends thence until it involves the greater 
part of both lids. The tuberose form may be met with in the same 
situation, but is more commonly observed upon the extremities. 
When occurring in the palms of the hands and soles of the feet, the 
tubercles are usually of small size, but very numerous, and give a kind 
of mottled character to the affected surface; and on the wrists and 
ankles the affection may assume a good deal of the typical appearance 
of keloid. 

Although the causes, of xanthoma, like that of so many other affec- 
tions, are obscure, some curious facts have been observed which seem 
to have some relation with its aetiology. A large proportion of recorded 
cases, probably half, have labored during the development of the dis- 
ease under jaundice, due to organic disease of the liver; and a large 
number also, as Mr. Hutchinson has pointed out, appear to have suf- 
fered largely from sick headache. [Some recent observations seem to 
show that there exists in certain families a hereditary predisposition to 
the plane form of this disease. It occurs, no matter what form it 
assumes, much more frequently in women than in men.] It may be 
added that in one or two cases the disease has been associated with 
diabetes. 

Treatment — No efficacious plan of treatment is known. 



LICHEN RUBER. 

Description. — This is the name given by Hebra to an affection which 
is to some extent, no doubt, papular, but has no affinity whatever to 
the affections commonly included under the name of lichen. It com- 
mences with the appearance of small colorless or reddish solid papules, 
unattended, for the most part, with itching. These tend to increase in 
number, and presently to coalesce at their margins so as to constitute 
smooth patches of uniform thickening and induration, the effect of which 
is to smooth away the finer furrows or creasings of the skin, to inter- 



SCLERODERMA. 



321 



fere with the free movement of parts, and to render the patient more or 
less hidebound. 

The disease begins symmetrically on various parts of the body, and 
may remain limited in its range, or may gradually spread over the 
whole surface. The papules, which never grow in size beyond a cer- 
tain point, increase in number, and finally blend in the manner above 
indicated. The skin then gradually becomes indurated and thickened 
apparently to two or three times its normal thickness, and it loses its 
sensibility in a greater or less degree. There are certain situations in 
which the effects of the disease, however wide its distribution, are most 
obvious : these are the hands, feet, face, and neck. The hands are 
affected mainly on their palmar aspects, but the convex surfaces of the 
metacarpophalangeal and phalangeal joints are also involved, and, in 
a less degree, the remainder of the backs of the fingers, which are apt 
to remain papular. The hands become stiff and almost useless, the 
fingers are maintained widely separated and semiflexed, and cracks are 
apt to appear over the convexities of the joints. The feet and toes are 
affected in a similar manner. The skin of the face becomes smooth 
and hard, the delicate wrinkles about the eyelids, forehead, and cheeks 
become more or less completely obliterated, and much of the patient's 
mobility of features and natural expression is lost. The color of the 
primary papules and of the infiltrated skin is said by Hebra to be red, 
and to have a tendency to yield thin scales. It is, however, sometimes 
pale, or of a pale dead-leaf color, and free, or almost free, from des- 
quamation. Hebra points out, also, that the nails become brittle, and 
either thin or thick ; that the hair is unaffected ; that the disease rarely 
undergoes amendment or cure ; and that the patient tends to become 
emaciated and to die in the course of years from exhaustion. He fur- 
ther states that the papilla? of the skin have been found after death to 
be hypertrophied, and the root-sheaths of the hairs thickened. 

Treatment — Arsenic in large doses, and cod-liver oil by inunction, 
are the only remedies which have been found beneficial. 



SCLERODERMA. (Scleriasis. Addison's Keloid. Morphcea.) 

Causation and Description. — Under the above series of designations 
have been described a number of morbid conditions of the skin, which 
are now generally admitted to be closely correlated, if not absolutely 
identical with one another. They are very rare, and consequently, 
although interesting, do not claim any lengthened consideration here. 

They are all characterized by the appearance of patches of induration 
and thickening of the skin, which vary in extent and shape; tend 
gradually to increase in size ; are attended often with tingling, some- 
times with anaesthesia ; are white and ivory-like, or of a pale yellowish 
or brown hue, sometimes mottled, sometimes surrounded by a halo of 
congestion or of discoloration ; are for the most part of long duration, 
and in their progress are apt to become faintly tubercular, or to desqua- 

21 



322 



DISEASES OF THE SKIN. 



mate, or even to ulcerate, and, when they finally disappear, to leave 
behind them more or less brownish discoloration, with atrophy and 
cicatricial seaming of the surface. The affected parts are for the most 
part smooth, scarcely, if at all, elevated above the general level, and 
incapable of being pinched up in a fold; and the thickening, although 
generally limited to the skin, involves sometimes also the subjacent 
connective tissue. The affection appears to consist anatomically in an 
over-development of dense connective tissue, associated with the accu- 
mulation of cells, resembling lymph-cells, in the sheaths of the small 
vessels. 

1. It is comparatively not uncommon to meet with a patch or group 
of patches of scleroderma on one side of the forehead, in the region of 
distribution of the fifth pair. The affection then usually remains limited 
to this region. It commences insidiously, perhaps, as a mere discolora- 
tion, gradually increases in size, and occasionally spreads to the hairy 
scalp, leading to circumscribed alopecia. It is very chronic in its prog- 
ress. 

2. Another variety of the affection, Dr. Fagge's circumscribed scle- 
riasis (scleroma), is that which Dr. Addison described under the name 
of true keloid, deriving the word keloid from ?.7}X)q (a spot produced, as 
it were, by burning). In this, which is also a very chronic affection, 
the patches commence in various ways, sometimes a mere loss or 
change of color, sometimes as a mere depressed smoothness, sometimes 
as a simple induration, attended or unattended with itching or tingling. 
The patches vary in shape, are sometimes round, sometimes oval, some- 
times band-like, sometimes irregularly polygonal or stellate, and not 
unfrequently send out promontories, as it were, or peninsulas, into the 
surrounding healthy skin. They vary in size, are sometimes no larger 
than a sixpenny-piece or shilling, but tend to increase, and thus some- 
times to involve very extensive area?. They are usually multiple, and 
new spots are apt to arise from time to time. Beyond the itching and 
tingling, the main source of discomfort is the interference which any 
considerable extension of the disease causes with the free use of parts. 
The patient becomes hidebound, and his fingers, hands, arms, or other 
parts which are affected, more or less distorted, fixed, and useless. This 
immobility is increased when (as often happens) the skin becomes adhe- 
rent to the subjacent tissues and when (as also occasionally takes place) 
subjacent muscles waste. The mucous membrane of the tongue, lips, 
and gums is sometimes involved in the disease. 

3. A third form of the disease, which Dr. Fagge designates diffused 
scleriasis (scleroma), is that to which the names sclerema, scleroma, scle- 
riasis, and the like, are more particularly given. It appears to have 
been almost exclusively observed on the Continent, and is mainly char- 
acterized by the rapid extension of scleroderma over large parts of the 
surface of the body. It seems frequently to have begun at the back of 
the neck, and thence to have spread to the face, back and front of the 
trunk, arms, and even over the whole surface. The tongue may be 
involved. The integument becomes thick, hard, ivory -like and smooth, 
the arms, hands, and fingers stiff and immovable, the face an expres- 



ELEPHANTIASIS. 



323 



sionless mask. The aspect and feel of the affected regions have been 
likened to those of a frozen corpse. 

None of the above varieties of scleroderma appears to be associated 
with any indications of constitutional suffering, the secretion from the 
kidneys and even that from the affected portions of skin remain normal. 
They are all more or less chronic in their course — the first two lasting, 
as a rule, for years, and leaving marked signs of their pre-existence 
behind, the last, however, often disappearing entirely in the course of 
a few months. Women appear to suffer much more frequently than 
men. In some cases (especially of the diffused form) the attack is said 
to have originated in exposure to cold or wet; but little or nothing 
further is known with respect to the causation of the disease. There 
is some evident resemblance between scleroderma and the later stages 
of lichen ruber, and still more between it and the early stages of ele- 
phantiasis Grsecorum, of which disease some authors regard its circum- 
scribed forms as mere varieties. 

Treatment. — No local measures seem to have been useful in the treat- 
ment of scleroderma. The constitutional remedies which have been 
employed include cod-liver oil, quinine, iron, arsenic, and iodide of 
potassium. 



ELEPHANTIASIS, (fflephas. Pachydermia. Barbadoes Leg. 

E. Arabum.) 

The condition to which the above names have been generally given 
is mainly a disease of tropical climates, and more especially of certain 
parts of India. Its chief characteristic is a more or less enormous 
hypertrophy of the connective tissue of certain parts of the body, 
associated with early implication of the lymphatic glands and vessels. 

Causation and Description. — Elephantiasis commences with an ery- 
sipeloid inflammation of the part about to become permanently 
affected, attended with febrile symptoms, and indicated by superficial 
redness and by general and deep infiltration of the tissues. At the 
same time the superficial veins and lymphatics generally become marked 
out by red painful indurated cords, and the corresponding lymphatic 
glands undergo considerable acute tumefaction. If an incision be made 
at this time, a large quantity of yellowish transparent fluid, having all 
the characters of lymph, and coagulating spontaneously, escapes. After 
a few days, probably, the inflammation subsides, but the swelling con- 
tinues in a greater or less degree. Subsequent attacks of inflammation, 
excited by various causes, supervene at irregular intervals — each attack 
adding to the mischief, and leaving behind it a tendency to still further 
hypertrophic development. The final result is that the part affected 
becomes largely, sometimes enormously, increased in bulk and altered 
in aspect. 

In some cases the hypertrophic condition is mainly confined to the 
skin and subcutaneous connective tissue; in some it involves the whole 



324 



DISEASES OF THE SKIN. 



extent of connective tissue between the skin and bone. In either case, 
but in the former more especially, the skin is liable to be much modified 
in texture and form ; sometimes it becomes coarsely papular or warty, 
sometimes studded with nodular elevations, sometimes undergoes ulce- 
ration ; and the epidermis (which often remains normal) may desqua- 
mate, or become thickened or horny, or assume the characters observed 
in ichthyosis, or become more or less deeply colored from the deposition 
of pigment-granules in the rete mucosum. The affected surface, more- 
over, may be anaemic, or more or less deeply congested, or livid. When 
the morbid condition extends deeply, fat, muscles, and nerves become 
compressed and waste, but the bones undergo hypertrophy, new layers 
and irregular outgrowths being developed, by means of which adjoining 
bones occasionally become organically united. 

Elephantiasis appears to consist primarily in an inflammatory hyper- 
plasia of the cellular elements of the connective tissue, in connection 
with which there is reason (according to Virchow) to believe that the 
roots of the lymphatic vessels are specially involved. Inflammatory 
hyperplasia of the elements of the lymphatic glands next ensues, with 
obstruction to the passage of lymph through them. Then this fluid 
stagnates in the lymphatic vessels, which sometimes become dilated 
even to their radicles in the cutaneous papillae ; and it presently accu- 
mulates in the interstices of the affected tissues, adding to their bulk 
and at the same time stimulating them to overgrowth. It is only in 
the early stage of the disease that the dilated condition of the lymphatics 
admits of ready detection. At a late period the morbid tissues are 
mainly characterized by the presence of a dense accumulation of white 
fibrous tissue. The lymphatic glands also, after a time, become the 
seat of fibroid change. 

The regions most frequently attacked with elephantiasis are the 
lower extremities and the genital organs. But other parts may be- 
come affected, inclusive of the female breast. In the first of these 
cases the disease may commence in the toes or about the ankle, and 
gradually involve the whole leg up to the knee. It rarely, however, 
rises above that point. In extreme cases the form and appearance of 
the affected member remind one of those of an elephant's leg, whence 
the common name of the disease. When the scrotum or labia are in- 
volved they often reach enormous dimensions ; the scrotum may attain 
a weight of 50 or 100 lbs., and is sometimes also the seat of hydrocele. 

Elephantiasis is mainly a disease of adult life, and is more common 
in men than in women. Its progress is slow, but is largely governed 
by the conditions under which the patient lives, or the care he takes of 
himself. Exposure to weather, fatigue, or exposure of the affected 
part to anything provocative of irritation or inflammation, is apt to 
aggravate it ; while, under opposite conditions, the disease may make 
but little progress, or remain stationary. There is nothing in it neces- 
sarily inimical to life ; but want of cleanliness or other accidental cir- 
cumstances may give rise to ulceration or gangrene, and thus life becomes 
imperilled. 

Elephantiasis does not appear to be a specific disease. Swellings 
and indurations of precisely the same kind are apt to occur in the 



ELEPHANTIASIS. 



325 



vicinity of old ulcers, and especially in parts which have undergone 
repeated attacks of erysipelatous inflammation. Only in the latter 
cases the hypertrophy rarely, if ever, goes on to that inordinate extent 
which characterizes the endemic elephantiasis of tropical countries. 

Treatment. — The treatment of elephantiasis should be mainly pro- 
phylactic; the patient who is suffering from it should be careful to 
avoid all causes of renewed inflammation; he .should keep the affected 
parts clean and cool, should not expose himself to cold or vicissitudes 
of temperature, should avoid all over-fatigue and all exposure of the 
parts to irritation or injury. Moreover, these should not be allowed 
to be pendulous. During the inflammatory stage antiphlogistic reme- 
dies may be had recourse to ; fomentations or cold lotions should be 
applied locally, with the object of preventing hypertrophy, and it may 
be of promoting absorption ; and the affected region should (if its form 
or position permit) be kept evenly and firmly bandaged. Hebra rec- 
ommends that the bandage be of cotton, and dipped in water at the 
time of application. He further recommends that, previous to the use 
of bandages, scales and crusts be removed by cataplasms, baths, or 
greasy applications, and that afterwards mercurial ointment be rubbed in. 

Elephantiasis Ly mphangiectodes . 

Causation and Description. — A condition, very closely related to that 
last considered, occasionally arises independently of all inflammation, 
at all events of all inflammation of the parts chiefly implicated. It is 
sometimes due to the continued application of a tight ligature to the 
upper part of one of the extremities, sometimes to obstructive disease 
in the lymphatic glands, or in the course of the lymphatic vessels, 
arising during adult life, and sometimes occurs as a congenital or in- 
fantile affection. In all of these cases the morbid condition appears to 
be chiefly, if not entirely, due to obstruction of lymphatics, with con- 
sequent dilatation of those below the seat of obstruction, accumulation 
of lymph in the textures, and overgrowth of the connective and other 
tissues. The lesions closely resemble those which occur in elephan- 
tiasis Arabum ; aud the resemblance is not unfrequently enhanced by 
the occasional supervention of attacks of inflammation. The disease 
appears to be not uncommon in tropical climates; and is attributed by 
Dr. Lewis to the presence of filarise in the blood, and to obstruction of 
the lymphatics by these entozoa. 

It generally first reveals itself by simple increase in bulk of the 
part affected. This increase goes on more or less insidiously, until the 
hypertrophy becomes considerable, the tissues more or less indurated 
and dense, and the surface pale, congested, or otherwise modified in 
color, and either smooth, papular, or tuberculated. After a time, 
groups of vesicles are apt to make their appearance, sometimes widely 
distributed, sometimes in an irregular patch, sometimes in a linear 
series, and generally imbedded, as it were, in the solid tissue. These, 
which are really dilated lymphatic spaces, are apt to rupture from time 
to time, and then to exude considerable quantities, sometimes several 
pints, of lymph, which coagulates after its escape, and is sometimes 



326 



DISEASES OF THE SKIN. 



yellowish and transparent, sometimes milky from the presence of 
molecular fat. This affection is usually limited to one of the lower ex- 
tremities or to the upper part of the thigh and contiguous part of the 
abdomen, or to the genital organs and perinseum ; and it may be added 
that there is good reason to believe (as is elsewhere pointed out) that 
chyluria is due to a similar affection involving the mucous membrane 
of the bladder or that of other parts of the urinary tract. When the 
lower extremity becomes affected in infancy, not only does the limb 
generally increase in bulk, but the bones, relatively to those of the 
opposite member, become manifestly hypertrophied — augmented both 
in thickness and in length. 



MOLLUSCUM CONTAGIOSUM. 

Causation and Description. — This is an affection mainly occurring 
among children, and characterized by the development of small globular 
or subglobular outgrowths from the skin, usually varying from the 
size of a pea downwards, but occasionally attaining larger dimensions. 
They are sessile, though sometimes attached by constricted bases. 
They differ little, if at all, in color from the surrounding skin, but 
have a slight degree of translucency. They are unattended with pain 
or itching. Each tumor presents for the most part a distinct depression 
in the centre of its convexity, from which can sometimes be expressed 
a little milky fluid or wax-like substance. On section it is found to 
consist of a lobulated gland-like body, the crypts of which are lined 
with columnar epithelium, and filled with rounded cells of large size. 
All these crypts communicate with a central duct, which for the most 
part is full of cells containing fatty matter. The growth appears in 
fact to be a kind of epithelioma. Molluscum has been supposed to be 
due to some abnormal development of the sebaceous glands ; but both 
Beale and Virchow regard it rather as taking its origin in the hair- 
follicles. We believe, however, that we have seen molluscous tumors 
in the palm of the hand. 

Whatever the nature of this disease may be, we consider that it has 
been clearly proved to be contagious. It frequently occurs simul- 
taneously among the children of a family, and occasionally even the 
adult members under such circumstances become affected. The parts 
on which the tumors chiefly appear are the face, head, and neck, and 
trunk ; they appear, however, also on the limbs. 

Treatment. — In the treatment of molluscum, local measures only are 
of use. If the tumors are attached by narrow bases they should be 
snipped off ; if by broad bases, they should be effectually cauterized 
with nitrate of silver, potassa fusa, acid nitrate of mercury, or the like, 
previous to which it may be well to lay them open with a scalpel. 



PHTHIRIASIS. 



327 



PHTHIRIASIS. (Lousiness.) 

Causation and Description. — Lice, the presence of which gives rise 
to the affection sometimes termed phthiriasis, are of common distribu- 
tion as parasites throughout the animal kingdom. Three varieties 
affect man, namely, the pediculus capitis, the pediculus vestimenU, and 
the phthirius (or pediculus) pubis. The first of these affects the head 
only; the second lives in the underclothing and feeds on those parts 
of the body which are uncovered with hair; the last infests only the 
hair of the pubes and armpits, together with the eyebrows and eye- 
lashes, whiskers, beard, and mustache. 

1. The pediculus capitis is generally of a gray color like that of the 
scurf, and hence is very readily overlooked ; it presents, however, a 
dark streak (alimentary canal) along the centre of its body, the pres- 
ence of which may aid in its detection. It lives among the hairs close 
to the scalp, feeding for the most part on the scurf and even on the 
hairs, and running along the latter with considerable agility. The 
female, which is larger than the male, deposits her eggs (nits) upon the 
hairs, attaching them thereto by a very tough transparent sheath. 
These, which may readily be mistaken for particles of scurf, are fixed 
upon the hairs very much as are the cocoons of some moths upon the 
stalks of grass, are furnished with a lid, and measure about half a line 
in length. The female, according to Kuchenmeister, begins to lay 
eggs at the end of eighteen days, and lays about fifty. The eggs be- 
come hatched in six days. 

Pediculi always cause more or less itching, and consequently a ten- 
dency to scratch the head with the nails. This may be all. But in 
many cases the irritation which they produce leads to the development 
of eczema or impetigo, and the formation of thick scabs. As Mr. B. 
Squire has pointed out, impetigo in children, limited to the back of 
the head, is often of pedicular origin, and impetigo affecting the nape 
of the neck in adults (especially females) is also commonly attributa- 
ble to lice. There is good reason to believe that the affection termed 
plica polonica is nothing more than a combination of filth, lice, and 
entanglement or felting of the hair. We may add, too, that pediculi 
(then termed p. tabescentium) are very apt to accumulate in the heads 
of patients suffering from long and wasting illnesses. There is, how- 
ever, no sufficient reason for regarding them as in any sense distinct 
from the common head-lice. 

2. The pediculus vestimenti is scarcely distinguishable from the last, 
excepting by its larger size, and by its habits. It lives in the under- 
clothing, and attaches its eggs to the superficial projecting fibres. It 
is not always easy to detect its presence, for it is only occasionally dis- 
covered crawling upon the skin, or even upon the plane surface of the 
shirt or chemise. It almost always lies concealed in the folds or pleats, 
and it is in these situations also that its eggs are deposited. The eggs, 
moreover, though almost exactly resembling those of the head-louse, 
have generally so much the color of the garment to which they adhere 
that they are discoverable with considerable difficulty. 



328 



DISEASES OF THE SKIN. 



Body-lice, like the last, often cause general itching only, but often, 
after a time, the constant irritation of their presence leads to the devel- 
opment of an indistinctly papular condition of the cutaneous surface, 
and bleeding points and lines, the consequences of violent scratching. 
This state of skin closely corresponds with the ordinary descriptions 
of prurigo — and, indeed, there can be no doubt that the great majority 
of cases of so-called prurigo senilis are essentially cases of phthiriasis. 
The presence of body-lice not unfrequently also causes urticaria, lichen, 
and eczema. 

3. The pediculus pubis, or crab-louse, is very different in form from 
the other species of louse. It presents a much broader thorax and ab- 
domen, and its chitinous claws are much more elongated and massive. 
It never affects any other parts than those which have been already 
named as its habitat, always nestling close to the skin, and biting 
deeply into it. It fixes its eggs, which resemble those of the head- 
louse, close to the points of emergence of the hairs. 

The pediculus pubis causes violent irritation, and frequently induces 
an impetiginous eruption and the formation of abundant scabs. 

Treatment — It is not generally difficult to get rid of lice. The 
thorough use of soap and water, and thorough personal cleanliness, 
are of course essential, but alone are not generally sufficient. Many 
local applications will destroy them, but none probably is more effica- 
cious than daily washing with decoction of staphisagria seeds, or the 
inunction of the parts (as recommended by Mr. B. Squire) with oil of 
stavesacre, diluted with olive oil, or the application of mercurial oint- 
ments, such as the ammonio-chloride. The application must of course 
be continued until all nits (as well as lice) are removed or dead. It is 
often desirable, in order to promote certainty and rapidity of cure, to 
hunt out and destroy the pediculi one by one, to pluck or cut out the 
nit-bearing hairs, or even to shave the head or other hairy parts. The 
applications which have been enumerated may be useful even in the 
treatment of the pediculus vestimenti, but the chief treatment here 
must be directed to the clothes. Not only, however, must these be 
frequently changed and washed, but the bedclothes must be similarly 
treated, as must also the clothes of any one sharing the same bed. 



SCABIES. {Itch.) 

Causation and Description. — Itch is an affection of the skin, de- 
pendent on the presence of the acarus scabiei, and marked by the 
development of a papular, vesicular, or pustular eruption, with intol- 
erable itching, which becomes especially violent in the evening and at 
night. 

The acarus scabiei is an animal not unlike a cheese mite, both in 
general form and in color, and is visible to the naked eye as a minute, 
white ovoid speck. Its body has a short oval form, is convex above, 
somewhat flattened below, studded with numerous spines and bristles, 



SCABIES. 



329 



and furnished (in the adult state) with eight legs. In the female the 
four front legs end in stalked suckers, the four hind legs in bristles. 
In the male the hindermost pair of legs, as well as the four front legs, 
present suckers. The acarus just escaped from the egg has six legs, 
the hindermost, or fourth pair, only making their appearance after the 
first change of skin. The male acarus is little more than half the 
length and half the breadth of the female. The egg, which is oval, 
measures about one-third the length of the adult female. 

The acari live for the most part in burrows (cuniculi), which they 
make for themselves in the substance of the epidermis, beneath its 
horny layer. According to Hebra, about a fortnight elapses from the 
time of hatching until the complete development of the animal. About 
the end of that time the impregnated female penetrates the corneous 
layer of the skin, and then slowly tunnels beneath it in a straight, or 
zigzag, or curved line. In its onward progress it deposits its eggs, 
sometimes as many as fifty, in a linear series, and at the end of two or 
three weeks, or it may be six (Hebra), it dies at the further end of its 
burrow. This may then have attained the length of half an inch, or 
an inch, or even more than that. It is generally quite obvious, on 
careful examination, as an irregular line, studded with subcuticular 
black matter (faeces), presenting at its commencement, in consequence 
of the gradual desquamation of the skin, a groove with retreating sides 
— a kind of calamus scriptorius — and at its opposite extremity a minute 
papule, in which the white body of the animal can generally be pretty 
readily distinguished. The formation of the burrow and its full devel- 
opment may be unattended with visible signs of inflammation, but not 
unfrequently papules, vesicles, or pustules rise up in its immediate 
neighborhood, the burrow then passing over them, or alongside of 
them, but very rarely forming any communication with them. Some- 
times strings of vesicles, running perhaps together, mark its whole 
length. The eggs contained within the burrow hatch there, and the 
young speedily migrate. The male acarus is difficult of detection, 
partly from its minuteness and comparative infrequency, and partly 
from the fact that it either imbeds itself simply in the skin without 
burrowing, or that it rambles over the general surface. 

The acari mostly burrow about the wrists and hands, especially on 
the palmar aspect, and between the fingers, and in the corresponding 
situations in the lower extremities ; they also infest the nipples and the 
organs of generation, the flexures of the elbows and knees, the axillae 
and the buttocks. No part can be regarded as necessarily exempt 
from their ravages. The face and head, however, are rarely attacked. 
The presence of the acari gives rise to intolerable itching, which in- 
creases at night-time, and provokes violent scratching. It also gives 
rise to inflammatory eruptions — papules, vesicles, blebs, or pustules — 
which are to be looked for especially on those parts of the surface which 
the acari chiefly affect ; and occasionally it induces urticaria, eczema, 
or impetigo, which are not necessarily limited to the neighborhood of 
the burrows, and may become general. The papular and vesicular 
forms of the eruption of itch are the most common. The pustular va- 
riety shows itself for the most part in persons who are out of health or 



330 



DISEASES OF THE SKIN. 



possess peculiarly susceptible skins. Sometimes the inflammation be- 
comes excessive, and produces not only pustules but considerable in- 
flammatory exudation and infiltration. This condition may often be 
observed on the penis and the nipples. The disease has naturally little 
or no tendency to spontaneous cure ; but can certainly be kept in abey- 
ance by personal cleanliness. Under opposite conditions, however, it 
is apt to become greatly aggravated. Occasionally the tips of the 
fingers and toes, with their nails, become destroyed, partly by the di- 
rect operation of the acari, partly by the ulceration which they induce. 
A very severe form of the disease, common in Norway (and hence 
termed Scabies Norvegica), but not confined to that country, is charac- 
terized by the formation of thick tough crusts extending over the 
palmar surfaces of the hands and fingers, and the corresponding sur- 
faces of the feet and toes, the parts beneath being excoriated or ulcer- 
ated. The crusts contain innumerable acari and ova, both living and 
dead. 

From the different degrees of severity which it presents, and from 
the very various eruptions to which it gives rise or with which it may 
be associated, itch is a disease which, on the one hand, is very apt to 
be overlooked w T hen present, and, on the other hand, very liable to be 
assumed as present when the patient is entirely free from it. The ap- 
pearance of a papular, vesicular, or pustular itching eruption between 
the fingers and about the wrists, and in other situations which itch 
affects, is no doubt an important indication ; but similar eruptions, not 
due to the acarus, occur in these same localities. The transference of 
the disease to a bed-fellow or to those with whom the patient has simi- 
larly close relations, is also a point of great significance ; but it must 
not be forgotten that one member of a household may have itch for 
months and yet fail to infect any of the other members. The only 
real proof of its presence is the discovery of the acari, their eggs, or 
their burrows. The burrows are sometimes marvellously well seen, 
presenting all the characters which have been already described ; they 
are often, however, incipient only, and very difficult indeed of recog- 
nition. When they are distinct the discovery of the female acarus is 
easy. It can generally be seen, even with the naked eye, at the further 
extremity of the burrow, or apparently a little beyond that point, as a 
very minute whitish papule. If the surface of this papule be torn with 
a pin, the acarus may readily be removed from its bed on the point of 
the instrument. In performing this operation it is well to avoid wound- 
ing any neighboring vesicle or pustule. Even in cases where no ob- 
vious burrow exists, the acari may be occasionally detected in the 
neighborhood of some of the itching papules by the presence there of 
the minute whitish elevations which they cause. Sometimes, even 
when distinct burrows are present, there is some difficulty in detecting 
the acari at their extremities ; in such cases one of the burrows may 
be broken down, and its contents removed on the point of a pin or 
lancet, or, still better, a whole burrow may admit of being cut out. By 
these means the ova may be readily obtained. A further plan is to 
remove the scabs, if there be any, to boil them in a solution of caustic 
socla until they become limpid, and, after allowing the fluid to stand 



OTHER SKIN AFFECTIONS CAUSED BY ANIMALCULES. 331 



for a time in a conical glass, to examine the deposit with a microscope. 
Dead acari, including males, and six-legged grubs, and ova, can often 
be obtained by this process. 

Treatment. — The essential object in the treatment of scabies is the 
destruction of the acari and their ova. For this purpose it is necessary 
not only to apply an appropriate parasiticide, but to soften the skin and 
remove its superficial epidermis so as to expose the burrowing mites to 
its influence. The patient therefore should have daily hot baths, use 
soap abundantly, and rub the surface thoroughly with a flesh-brush or 
a rough towel. All scabs should be removed. Then sulphur oint- 
ment, either of those of the Pharmacopoeia, or that of Heltnerich, 
which contains carbonate of potash, should be rubbed well into the 
skin, especially into those parts which seem most affected, and should 
remain upon the skin until the next bath. Treatment of this kind 
will generally cure the affection in the course of a few days or a week, 
but may not improbably induce eczema or some other form of super- 
ficial inflammation, which will need other remedies for its cure. No 
doubt less active measures will suffice to cure scabies, but the cure will 
then be probably long delayed. On the whole, however, when a per- 
son has itch it is better for himself, in the long run, and better for 
those with whom he associates, that he should recognize his condition, 
retire for a few days from public life, and adopt the measures which 
will most speedily work a cure. Tincture of benzoin and balsam of 
Peru, far more agreeable applications than sulphur, are said to be more 
efficacious than it in the cure of itch. They should be rubbed well 
into the affected parts. The purification of the patient's clothes and 
bedclothes forms an essential part of the treatment. 



OTHER SKIN- AFFECTIONS CAUSED BY ANIMALCULES. 

Causation and Description. — Fleas, bugs, and gnats do not of course 
come under the category of parasitic animals. So many persons, how- 
ever, suffer from their bites, and the effects of their bites are so often 
misinterpreted, that it seems desirable to make a remark or two here 
in reference to them. A recent flea-bite always exhibits a punctiform 
subcutaneous extravasation of blood, surrounded by a comparatively 
broad rosy areola. The latter soon disappears ; the former may per- 
sist for several days. People, and especially children, of the lower 
classes are often thickly covered with such petechial spots in different 
stages of their progress ; and their skin, when seen for the first time 
(especially if they be suffering from some febrile disturbance), is very 
apt to suggest the presence of the typhus eruption. The small ness, 
however, of the spots, their uniformly petechial character, and the 
probable detection in them on close inspection of the puncture made 
by the insect, will alone, for the most part, enable a careful observer to 
distinguish the eruption due to fleas from that of any of the specific 
fevers. In some persons flea-bites produce very considerable irritation 



332 



DISEASES OP THE SKIN. 



and the development of wheals or tubercles, associated sometimes with 
a large amount of subcutaneous effusion of serum. The effects are 
then not unlike those which commonly arise from the bites of gnats 
and bugs. In all these cases there is generally in the first instance 
much violent itching, which is followed presently by the formation of 
a wheal or tubercle from the size of a split pea downwards, and very 
often by more or less considerable subcutaneous oedema. The latter 
pretty soon subsides ; but the wheal probably continues for a week or 
fortnight, and is generally attended with violent itching during the 
whole of that time. In its progress there is generally (owing in some 
measure to scratching) effusion of points of blood into its central part, 
and this is succeeded sometimes by vesication, sometimes by the forma- 
tion of a pustule. Sometimes the wheals gradually subside and disap- 
pear ; but in many cases their subsidence is attended with the separa- 
tion of a squama, or the formation and detachment of an eschar, or, 
when there has been vesication or suppuration, the production of a 
scab. It need scarcely perhaps be said that gnats generally select ex- 
posed parts of the skin, fleas those regions which are protected by 
clothing, and that bugs are more indiscriminate in their attacks. 
There is no doubt that the bites of these insects, especially in children 
of delicate skin, produce eruptions the source and nature of which are 
apt to be entirely overlooked. Very many attacks of so-called " stro- 
phulus," " lichen/ 7 and " impetigo," ascribed to dentition, dyspepsia, 
and other causes, are really due to the operations of the above animals. 
The effects of mosquito bites are almost identical with those of gnat 
bites ; their bites, however, are generally much more numerous and 
individually more venomous. 

The leptus autumnalis, or harvest-bug, which is of common occur- 
rence in the autumn in grass and cornfields and among gooseberry 
bushes, is very apt to imbed itself in the skin, and to cause much irri- 
tation there. The effects pass off in about a week. The mite is just 
visible to the naked eye. It is of a red color and presents six legs. 
It is probably the immature condition of an unrecognized eight-legged 
animal. 

The pulex penetrans (chigoe) is a native of South America and the 
West Indies. It is so small as to be seen with difficulty, and is char- 
acterized by the possession of a proboscis as long as its body. The im- 
pregnated female only attacks man. It penetrates the skin of the feet 
and toes, generally in the neighborhood of the nails, where its impreg- 
nated body quickly develops itself into a white vesicle the size of a 
pea. This enlargement is due to the rapid growth of the larvre, which, 
if the cyst be ruptured, escape into the surrounding tissues and cause 
in them severe inflammation with suppuration. The recognized mode 
of treatment is to dilate with a needle the orifice by which the intruder 
entered, until it is large enough to allow of its extraction without 
rupture. 

On the Island of Bulama and its neighborhood, on the West Coast 
of Africa, a pimple ultimately attaining the dimensions of a boil, and 
then attended with much pain and surrounding inflammation, and 
even affection of the neighboring lymphatic glands, is attributable to 



TINEA TONSURANS. 



333 



the grub of some insect, which is deposited doubtless in the egg be- 
neath the skin, and attains its full growth in that situation. The per- 
fect insect is not known. 

The acarus (demodex) folliculorum resides in the sebaceous follicles, 
for the most part either in the duct or close to the hair about the spot 
at which the sebaceous follicle opens into that of the hair. It is slug- 
gish in its habits, and lies imbedded in the sebum with its head pointed 
inwards. The number of acari in a follicle vary from one upwards. 
As many as thirteen have been discovered at one time (Kiichenmeister). 
They differ in size, and in some degree in form, with age. In the earlier 
period of their development they present six and subsequently eight 
legs. They are most commonly found in the comedines of persons 
suffering from acne punctata, but are not certainly known to cause this 
affection, or even to aggravate it. In order to discover them the ex- 
pressed sebum should be diluted with oil, and then submitted to micro- 
scopic examination. This parasite causes no distinctive symptoms in 
man. It is said, however, to produce serious and sometimes fatal con- 
sequences in the dog. 



TINEA TONSURANS. (Porrigo Scutulata. Ringworm.) 

Causation and Description. — Ringworm depends upon the presence 
of a fungus, termed tricophyton tonsurans, which chiefly affects the roots 
and shafts of the hairs, but also invades the epidermis and the nails. 
Its mycelium consists of filamentous jointed branching tubes, which in 
the hair generally run in groups parallel with its long diameter, in the 
epidermis and nails form an irregular interlacement. The spores are 
minute oval or rounded bodies, formed, in the first instance, in linear 
series at the extremities of the mycelial filaments ; but they are soon so 
abundantly developed that their relation with the filaments is entirely 
lost. Spores form both in the epidermis and in the nails, but their 
chief seat is the shafts of the hairs within and a little external to the 
skin. The fungus spreads superficially, as do most fungi, in gradually 
enlarging circles, which, however, from various accidental circumstances, 
often expand irregularly, and often, when they are large, break up into 
irregular segments, and often, moreover, present fits of alternate qui- 
escence and growth. 

When ringworm occurs on the non-hairy skin, it reveals itself first 
as a slightly raised roundish uniformly erythematous patch, a line or 
two in diameter. This then slowly increases in size, becoming at the 
same time more distinctly circular ; and when it attains perhaps half 
an inch in diameter the inflammation at the centre begins to subside, 
and the patch thus becomes a ring. In its further progress the ring 
may enlarge to the size of half a crown or a crown, and still extending 
(but then for the most part irregularly), may creep, for example, over 
the whole side of the face or the entire surface of the chest. The margin 
of the patch is always red and elevated, but varies in breadth, and 
often presents papules or vesicles; and hence the affection has been 



334 



DISEASES OF THE SKIN. 



called indifferently erythema circinatum, lichen circinatus, and herpes 
circinatus. The central area, even if all inflammation appears to have 
subsided in it, still retains a yellowish or brownish discoloration, and a 
tendency to scale. Moreover, fresh spots of inflammation are apt to 
appear here and there upon it. Occasionally, patches of ringworm pre- 
sent two or three concentric erythematous rings, separated by rings of 
fairly healthy integument. There is no doubt that this variety has 
often been termed erythema, lichen, or herpes iris. 

When the nails are attacked, which is very rare, they become in the 
affected parts irregular, thick, softer than natural, and at the same time 
more or less opaque and of a yellowish tint. The fungus penetrates 
them generally from the root, and not un frequently the adjoining sur- 
faces of the fingers, and the hands, are at the same time involved. 

The most important, if not the most common seat of ringworm, is 
the head. Here the circular form of the affection and its erythematous 
or vesicular margin are rarely distinguishable. The patches, however, 
are generally well-circumscribed, and are indicated, partly by an abun- 
dant formation of adherent glistening scurf, which clings around the 
bases of the hairs, and is continuous with the lining of the hair-sheaths, 
and, by its peculiar scaly character, has given to ringworm one of the 
names, porrigo scutulata, by which it was formerly known ; and partly 
by the condition of the hairs, which become swollen, dull and opaque, 
limp and lacerable, so that they break off either at the surface of the 
scalp, or a line or two above it. This breaking off of the hairs pro- 
duces a marked resemblance to a stubble-field, and has suggested the 
common name of the disease, t. tonsurans or tondens. This stubbly 
character may be concealed, and the surface rendered apparently bald 
by accumulation of scurf. On removal of this many of the broken 
hairs are removed with it. 

Ringworm sometimes in men attacks the beard, mustache, and 
whiskers, producing one of the varieties of sycosis. It there excites 
(as it does occasionally in the scalp) considerable inflammation, causing 
deepseated suppuration about the sebaceous glands and roots of the 
hairs, and is very intractable. 

Ringworm is generally attended with more or less itching, especially 
if the head be the part affected. It is highly contagious, and is partic- 
ularly liable to spread amongst children. Adults, however, especially 
those who are in attendance on affected children, often take it. But in 
them it is for the most part limited to the non-hairy skin, the nails and 
fingers. Many suppose that it mainly attacks those who are in en- 
feebled health. But this is very doubtful. AVhen it affects the general 
surface it can, for the most part, be easily cured. In the head, however, 
or the beard, or nails, its cure is extremely difficult and long protracted. 
Children may suffer from it for several years ; and we have known it 
to persist in the finger-nails of an elderly lady for at least seven years, 
never during that time extending to other parts of her body. Tinea 
tonsurans affects the horse and some other of the lower animals. 

Treatment. — The treatment of tinea tonsurans is purely local, the 
main object being to destroy Or to remove the fungus which produces it. 
Many substances are recommended as parasiticides, the most important 



TINEA FAVOSA. 



335 



being the sulphurous acid of the Pharmacopoeia, and empyreumatic 
substances, such as unguentum picis liquidum (diluted or not), unguentum 
creosoti, oil of cade, and the like. In the treatment of ringworm of 
the head or beard, it is of great importance that the surface should be 
maintained close clipped or shaven, and kept, by washing with carbolic 
soap and water, quite free from scales or other forms of exudation. 
Further, it is most desirable that all affected hairs should be removed 
from the morbid patches by daily diligent epilation. After each daily 
washing and epilation the specific medicament should be applied and 
kept applied ; sulphurous acid by means of several folds of lint satu- 
rated with the solution and covered with oiled silk or paper ; ointment 
by being rubbed in and then left in a thick coat on the surface. In 
the case of ringworm of the body, the same measures as to cleanliness 
and specific applications may be pursued ; but here it is often advan- 
tageous to destroy the affected surface of the skin with some caustic, 
such as nitrate of silver, strong acetic acid, iodine paint, or blistering 
fluid. When the nails are involved, the surface should be removed 
in slices, and sulphurous acid or creosote ointment freely and constantly 
applied. 

Ringworm of the head and beard is very apt to reappear weeks or 
even months after apparent cure. The reason of this is of course 
obvious. It is most important therefore that the treatment should be 
prolonged far beyond the period of apparent cure, and that the hairs 
of affected areas should be from time to time carefully examined. Dr. 
Duckworth has recently pointed out that if a few drops of chloroform 
be dropped on suspected portions of the head, diseased hairs become 
of an opaque yellowish-white color, the healthy hairs remaining un- 
affected. 



TINEA FAVOSA. (Favus. Porrigo Favosa and Lupinosa.) 

Causation and Description. — The cause of favus is the growth in 
the skin of the fungus known as the Achorion Sehonleinii. This con- 
sists in a jointed mycelium differing little from that of the tricophyton 
tonsurans, and like it invading the epidermis, the nails, and the hairs. 
It differs essentially, however, from the tricophyton in the seat and 
character of its fructification. The formation of sporules commences 
with the development of short rounded joints at the extremities of 
certain of the mycelial tubes, and a complex development therefrom of 
other sporules by a process of budding. The first appearance to the 
naked eye of fructification consists in the development of minute disk- 
shaped sulphur-yellow spots beneath the horny layer of the epidermis, 
or of minute yellow cups at the points of emergence of hairs. These 
gradually increase in size, until they form yellow cupped disks from J 
to i inch in diameter, through the centres of which hairs not unfre- 
quently pass. On breaking these masses up they are found to be white 
and brittle, and microscopically to consist of sporules seated in a finely 
granular matrix. 



336 



DISEASES OF THE SKIN. 



The early stage of favus, which is commonly overlooked, and is 
most obvious when the disease attacks the smoother parts of the body, 
consists, like that of ringworm, in the appearance of small circles of 
erythema, which soon enlarge and become rings, the margins of which 
may be studded with papules or vesicles. These rings of herpes or 
lichen circinatus rarely grow larger than a sixpence or a shilling and 
are at first absolutely undistinguishable from those of ringworm ; but 
soon there appear here and there at the edges, or within the disks, the 
minute yellow points of fructification, which rapidly attain their full 
dimensions. The fully-formed favi, if discrete, maintain their char- 
acteristic form and appearance ; but where many of them are developed 
in close contiguity with one another they are apt to blend, and before 
long to form prominent, irregular, mortary masses, crossed by an im- 
perfect network of undermined epidermis, and presenting collectively 
an apj)earance suggestive of a rupial scab. Not unfrequently the prog- 
ress of the affection is attended with considerable inflammation, and 
even suppuration, the products of which blend with those of the vege- 
table growth. Under these circumstances the neighboring lymphatic 
glands also become inflamed. As a rule, however, favus is attended 
with but little local irritation, and but little itching. It is characterized 
generally by a peculiar mousy odor. 

Favus most frequently attacks the head, and leads in the part which 
it affects to the falling out of the hair, and to the growth in its place of 
thin, colorless, woolly hairs, and subsequently very often to the total 
destruction of the hair-follicles, and permanent baldness. The affected 
hairs, however, are not rendered brittle, like those in tinea tonsurans, 
and do not therefore break off. Nails attacked with favus do not differ 
appreciably from those which are the seat of ringworm. 

Favus is of very rare occurrence in England. In Scotland it ap- 
pears to be much more common. It is almost entirely limited to per- 
sons of filthy habits, and generally commences in childhood. When 
treated in its early stage it is easily cured ; but when it has infected a 
large area it is exceedingly intractable, and will often (notwithstanding 
careful treatment) persist for many years. That this, like other para- 
sitic diseases, is infectious, is beyond doubt ; nevertheless, it is re- 
markable how rarely (compared with tinea tonsurans) it spreads among 
children, or from one member of a family to another. Favus is a 
common and fatal disease in mice. Cats also sometimes suffer from it. 

Treatment — The principles and details of the treatment of favus are 
as nearly as possible identical with those of the treatment of ringworm. 
In the first place all the favi should be removed by washing, poulticing, 
or the employment of oleaginous applications. Then the surface should 
be kept scrupulously clean, and treated by such parasiticide remedies 
as are useful in ringworm. Persistent epilation is of essential impor- 
tance. In severe cases it is necessary to continue the treatment for many 
months, a year, or longer. Yet even when thus apparently cured, it 
not unfrequently breaks out again as soon as remedial treatment is 
discontinued. 



TINEA VERSICOLOR — ALOPECIA AREATA. 



337 



TINEA VERSICOLOR. {Pityriasis Versicolor. Chloasma.) 

Causation and Description. — This disease is caused by the growth 
among the epidermic cells of a fungus, termed the microspor on furfur. 
The mycelial tubes are about equal in thickness to those of the fungi 
which have been above described, but their texture is more delicate. 
They form an interlacement in the substance of the epidermis, but do 
not invade the hairs or nails. The spores are developed in micro- 
scopic clusters, somewhat resembling bunches of grapes, scattered here 
and there among the mycelial tubes, and seem to originate within buds 
springing from the sides or ends of certain of the cells of the mycelium. 

Chloasma is characterized by the formation of light-brown or liver- 
colored spots, which are slightly elevated above the general surface 
of the skin, covered with a more or less abundant branny scurf, and 
attended with a slight degree of itching. The primary spots have 
a circular outline, and vary perhaps from the third or fourth of an 
inch in diameter downwards. In the first instance a few such spots 
appear here and there. These increase in size, and soon other similar 
spots are developed in their vicinity. By degrees neighboring spots 
blend, and thus more or less extensive tracts of skin become pretty 
uniformly covered, the edges still presenting a sinuous character, and 
the neighborhood numerous outlying solitary and coalescing islets. 

Chloasma seems never to attack children, and very rarely persons 
of cleanly habits and among the better classes of society. It is a 
disease of adult life, and not unfrequently appears in those who are 
consumptive or otherwise out of health. It usually commences on the 
chest or between the shoulders ; and from thence may spread over the 
abdomen and the back, to the shoulders, upper arms and even forearms, 
and to the buttocks and thighs. But it never affects uncovered parts. 
This circumstance, together with the fact cf its occurring mainly in 
those who wash little and rarely change their linen, seems to indicate 
that the disease originates in filth. Like other parasitic diseases it is 
contagious, but its contagiousness is not well marked. 

Treatment. — In the treatment of chloasma perfect cleanliness is nec- 
essary. The affected parts should be daily washed with soap and 
water and well scrubbed with a flesh-brush or a rough towel ; after 
which one of the parasiticide applications should be well rubbed in. 
Under these measures the disease soon becomes apparently cured. Its 
complete cure, however, demands persistence in treatment long after 
all visible traces of the disease have disappeared. 



ALOPECIA AREATA. 

(A. circumscripta. Porrigo or Tinea, Decalvans.) 

Causation and Description. — This is mainly an affection of the hairy 
scalp, but occasionally also involves the eyebrows and eyelashes, the 

22 



338 



DISEASES OF THE SKIN. 



beard and whiskers, the hair of the armpits and pubes, and, it may be, 
even the general surface of the skin, and is characterized by the tem- 
porary or permanent loss of hair in more or less distinctly circumscribed 
patches. 

A well-developed patch of alopecia areata of the scalp is usually 
quite unmistakable. It is a well-defined bald area, of circular or sinu- 
ous outline, for the most part clean, smooth, and shining, and free from 
congestion or scurfiness. The skin indeed appears to be, if anything, 
thinner than in health, and the orifices whence the hairs should emerge 
are atrophied and indistinct. The patch may be perfectly bald in the 
greater part of its extent, or present here and there groups of such 
downy hairs as constitute the lanugo ; but not unfrequently a few long 
hairs still stud its surface at distant intervals ; and almost invariably 
in the neighborhood of these and of the margins may be seen on close 
inspection short club-shaped hairs, varying from about a line to J or 
even J inch in length. These latter are most obvious in dark-haired 
persons, from the fact that each clubbed extremity still presents the 
natural dark color, while the portion of shaft between it and the sur- 
face of the scalp becomes more and more attenuated and more and more 
devoid of color as it approaches the scalp. They can be pulled out 
more readily than healthy hairs, but are still generally attached with 
some degree of firmness. The presence of these clubbed hairs may 
be taken as indicative of the extension of the disease. When the 
affection has become arrested, downy hairs begin to show themselves 
over the bald area; and these may gradually assume all the characters 
presented by the surrounding: healthy hairs, or they may become coarse 
and white or otherwise modified in color, or they may remain weak and 
scanty. Sometimes new hairs grow up in the centre, while the disease 
is still spreading circumferentially. 

Alopecia areata is for the most part of chronic progress, lasting 
generally for months, often for years, or even for a lifetime. In 
some cases the patient presents only one or two circular spots, which 
enlarge up to a certain point and then undergo resolution. In some cases 
the disease continues to extend indefinitely, partly by the enlargement 
of old patches, partly by the development of new ones, until the greater 
portion of the scalp or even the whole scalp is involved, and until it 
may be the eyelashes and eyebrows, one after the other, and finally all 
other collections of hair disappear. In some instances the progress of 
the disease is acute, the hair falling out rapidly and generally, though 
still perhaps more or less patchily. The final issue of the disease is 
uncertain. In the great majority of cases recovery takes place after a 
longer or shorter time; but it is important to note that there is often a 
tendency for the disease to recur at irregular intervals, and not neces- 
sarily in the part originally affected. In no inconsiderable number of 
cases, and especially in those in wmich extensive tracts of surface have 
suffered, complete restoration of the hair never occurs; and in a few, 
absolute and permanent general alopecia ensues. 

The clubbed hairs above referred to present certain peculiarities on 
microscopic examination. The clubbed end is usually broken into a 
brush, and frequently presents in its interior an irregular group of 
largish cells, which are evidently the cells of the axis of the hair at 



ALOPECIA AREATA. 



339 



that part, modified in character. From this point downwards the hair 
becomes more and more attenuated, until it ends in a very slightly di- 
lated point, which represents the imperfect root. Occasionally, a little 
below the clubbed extremity, the dwindling shaft is interrupted by a 
small knot, within which such a group of cells exists as is usually 
found in the clubbed end itself. Looking to the fact of the occurrence 
in the originally healthy hair, at a point which seems to separate the 
normal from the attenuated portion of a spot in which there has been 
some sudden modification of nutrition and growth which renders the 
hair at this part brittle and peculiar in structure, and to the fact that 
the portion of the shaft subsequently formed becomes, in consequence 
of the gradual wasting of the hair-root, more and more attenuated, until 
it falls out bodily, it would seem pretty certain that the diseased pro- 
cess, as it affects the hairs, depends on the gradual spreading from some 
central point or points of a wave of inflammatory or other influence, 
which, as it passes over each hair-papilla, momentarily excites it as it 
were to unhealthy over-production and then leaves it enfeebled and 
perishing. This disease is asserted by Bazin and many others to be 
parasitic, and clue to the presence of the microsporon Audouini. 1 There 
can be little doubt, however, that this view is erroneous. It is believed 
also by many to be contagious; but this again, is doubtless an error. 
It is certain, however, that it is apt, like psoriasis, to break out periodi- 
cally in the same individual, and like that also to affect several mem- 
bers of the same family, and to be transmissible from parent to child. 
The disease is more common in children than in adults, and in females 
than in males. We have seen it in a child ten months old, and it is 
often met with, still progressing, in persons between forty and fifty. 
Its presence is neither preceded nor accompanied by any general signs 
of ill-health ; nor is its progress usually attended with any subjective 
local symptoms. Occasionally its commencement and spread are marked 
by more or less intense tingling or itching, so that the patient not only 
knows, before the hair falls out, when a new batch of disease is com- 
mencing, but knows also when an old patch is spreading. 

Treatment. — The treatment of alopecia areata is very unsatisfactory. 
Many patients get well who are never subjected to treatment, and many 
go on progressively from bad to worse in spite of the most sedulous care. 
There are no obvious indications for constitutional treatment, but tonics 
and arsenic are often employed empirically. For local treatment it is 
generally thought best to use stimulants, and especially to blister the 
affected regions periodically with the acetum cantharidis or iodine paint. 
We do not believe that shaving the head is of any use, excepting for 
the purpose of facilitating the application of local remedies. It may be 
added that those who believe in the parasitic nature of the disease would 
naturally recommend the use of creosote, sulphurous acid, or other para- 
siticides. 



1 Recently M. Melassez claims to have rediscovered the specific fungus of this 
disease. He has seen spores of indeterminate character, and in very small numbers, 
in the horny layer of the epidermis — none in the rete mucosum, none in the hairs. 
They are doubtless accidental ; at all events there is absolutely no ground for re- 
garding them as the cause of the disease. — Archiv de Physiologie, 1874. 



340 



DISEASES OF THE SKIN. 



PRURIGO. 

Description. — This name is given to a condition of the skin attended 
with more or less violent itching, marked by more or less coarseness of 
texture, and usually by the presence of scratches produced by the action 
of the finger-nails. It is uncertain whether there is any specific affec- 
tion to which the name is applicable. Willan obviously included 
under this term mere pruritus, or itching from various causes, and espe- 
cially that due to the presence of body-lice. But he also included a 
papular affection which he regarded as quite distinct from other varie- 
ties of papular diseases. Hebra also describes a similar affection, which 
he considers to be sui generis, and to which he limits the use of the 
name. 

According to the latter authority, prurigo is a disease of remarkable 
intractableness, if not incurable, consisting in the development of flat 
papules, not differing in color from the skin, scarcely appreciable by 
the eye, but readily detectable by the touch, and leading to a general 
coarseness of texture and more or less pigmental deposit. It may occur 
upon nearly all parts of the body, but rarely attacks all in the same 
individual ; and it especially affects in an increasing ratio the front and 
back of the trunk, the extensor aspects of the upper arms and thighs, 
forearms and legs. The papules are apt to be irritated into inflamma- 
tion, or torn by scratching, and the eruption to be complicated, after a 
time, with eczema, impetigo, urticaria, and the like. Notwithstanding 
Hebra's authority, it may still, we think, be a question whether 
prurigo does not represent a heterogeneous group of ill-developed or 
ill-defined affections, attended with the common symptom of intense 
itching, and in which a coarse subpapular condition of skin is present, 
in consequence partly of some abnormal nutritive condition of the skin, 
partly of the influence of constant scratching and other varieties of 
irritation. According to this view, prurigo may be a legacy left by 
eczema, impetigo, or erythema ; or it may be present in persons liable 
to these affections during the periods when they seem to be free from 
them; or it may be referable to phthiriasis or scabies, to jaundice or 
uraemia, to want of cleanliness, to the irritation produced in delicate 
skins by the too abundant and too frequent use of soap, or to excessive 
friction either by the towel or by the clothes. 

Treatment. — For the treatment of prurigo, Hebra especially recom- 
mends sulphur, in the form of ointment, baths, or fumigation, and tar 
in its various preparations, or creosote, and frequent bathing. Besides 
these remedies lotions may be employed containing opium, prussic 
acid, acetate of lead, acetate of ammonia, or vinegar, or else black- 
wash, or mercurial or plumbic ointments. The constitutional treat- 
ment of these cases must depend on the patient's general symptoms or 
state of health, or on the nature of the ailment to which the pruritus is 
referable. When the itching is due to parasitic affections, parasiticide 
applications must be employed. 



DISEASES OF THE RESPIRATORY ORGANS. 



341 



CONCLUDING REMARKS. 

Besides the various affections of the skin which have just been 
passed in review, there are many others, of more or less interest, which 
could not be omitted from a work devoted to skin diseases, yet scarcely 
call for consideration in a manual of medicine. They are either of no 
practical importance, or are extremely rare, or fall entirely within the 
domain of the surgeon, or are mere symptoms of more important dis- 
orders, and are consequently considered, so far as is necessary, elsewhere 
in this volume. We more particularly allude to such hypertrophic 
affections as horns, corns, warts, nsevi, fibromatous and fatty tumors, 
epithelioma, and other varieties of malignant disease which affect the 
skin primarily or secondarily, and form either circumscribed tumors 
or infiltrating growths; to various atrophic conditions of the skin, 
hair, and nails, inclusive of the condition to which Dr. Wilks has given 
the name of linear atrophy; to increase or diminution of pigment 
(ephelis, lentigo, vitiligo, albinism) ; to the eruptions characteristic of 
many specific febrile disorders ; and to such rare and ill-understood 
affections as framboesia, pellagra, and acrodynia. 



III.— DISEASES OP THE RESPIRATORY ORGANS. 

INTRODUCTORY REMARKS. 

Anatomical Relations. 

1 . The organs of respiration comprise the larynx, trachea, bronchial 
tubes, lungs, and pleurae. 

Larynx and Trachea. — The larynx is situated in the upper and fore- 
part of the neck, extending from the hyoid bone above to the lower 
border of the cricoid cartilage below. The trachea commences at the 
lower border of the larynx, on a level with the upper orifice of the 
oesophagus and the fifth cervical vertebra, and runs downwards in the 
mesial line to the level of the third dorsal vertebra, where it divides 
into the two bronchi. The upper half of it is situated in the neck, 
the lower half in the chest, behind the sternum. Behind, it lies in 
contact in its whole length with the oesophagus. In front, it is em- 
braced above, as low down as the fourth, fifth, or sixth ring, by the 
thyroid body, and below, just above its bifurcation, is crossed by the 
transverse arch of the aorta. The roots of the lungs are situated in the 
posterior mediastinum, on the level of the bodies of the fourth and 
fifth dorsal vertebrae; the right bronchus, which is nearly horizontal, 
being on the level of the fourth vertebra behind and second costal car- 
tilage in front ; the left, which passes down obliquely, reaching as low 



342 



DISEASES OF THE RESPIRATORY ORGANS. 



down as the fifth vertebra behind, and a little below the second costal 
cartilage in front. The latter passes under the aortic arch and is in 
contact therefore above with the transverse arch, behind with its de- 
scending portion. 

Lungs. — The apex of each lung rises above the first rib into the 
root of the neck and the posterior obtuse margin occupies the groove 
between the ribs and vertebrae as low down as the eleventh rib. The 
base of the lung varies in position with the varying position of the 
diaphragm. The vault of the diaphragm rises during expiration on 
the right side to the level of the fifth rib at the sternum, on the left 
to the level of the sixth, and of course therefore the liver on the right 
side and the stomach on the left attain these respective elevations. 
The outer margin of the base, however, owing to the upward convexity 
of the diaphragm, reaches to a lower level, and during medium dis- 
tension of the lungs with air may be traced in nearly a direct line from 
the junction of the sixth costal cartilage with the sternum outwards 
and downwards to the head of the eleventh rib. During deep inspira- 
tion the edge may descend considerably between these extreme points. 
The anterior margin, like the lower one, varies in its position during 
the respiratory acts. When the lungs are moderately full their anterior 
borders are separated above by a triangular interval, the base of which 
corresponds to the sternal notch, the apex to the lower edge of the 
manubrium. From this point downwards to the interval between the 
fourth ribs, they continue parallel and nearly in contact. They then 
separate again, the edge of the right lung still passing vertically down- 
wards, while that of the left retreats, forming .a notch of which the 
apex corresponds to the junction of the fifth costal cartilage and rib, or 
to a corresponding point in the fifth interspace, and within which the 
heart becomes superficial. After a deep inspiration the anterior edges 
of the lungs are usually in contact from above down to the commence- 
ment of the cardiac notch ; after a deep expiration there may be an in- 
terval of an inch or two between them. The extreme apex of the 
lower lobe of either side is situated behind, and in the adult about 
three inches below the summit of the lung. 

Pleurce. — The cavities contained by the parietal pleurae correspond 
pretty accurately to the forms of the lungs; they are, however, only 
fully occupied by the lungs when these latter are largely inflated. 
During ordinary respiration there is a portion of each pleural cavity 
beyond the lower margin of the lung, and another beyond the anterior 
margin, in which opposed portions of the parietal pleura are in contact 
with one another. It must be added to this statement that the pleurae 
do not line the thoracic parietes quite down to the attachment of the 
diaphragm in front ; and that, while the anterior margin of the right 
pleura extends to the mesial line of the sternum from the level of the 
second rib downwards, that of the left retreats somewhat at about the 
point at which the notch in the left lung commences. 

2. Regions of Chest. — It is usual and convenient for clinical purposes 
to map out the chest into regions. The names of those which are gen- 
erally recognized sufficiently indicate their respective positions. They 
are as follows : in front, the supra-sternal, situated immediately above 



PATHOLOGY OF VOICE. 



343 



the sternal notch : the upper sternal, corresponding to the upper half, 
the lower sternal to the lower half, of the Sternum ; the supra- clavicular, 
placed just above the inner half of the clavicle; the clavicular, corre- 
sponding to the inner half of the same hone; the infra-clavicular, ex- 
tending from the clavicle downwards to about the level of the third 
rib ; the mammary, of which the nipple may be taken as the centre, 
extending from about the third to the sixth rib ; and the infra-mam- 
mary, comprising the remainder of the front of the chest; at the side, 
the axillary, bounded by the summit of the axilla above, and extend- 
ing halfway down the thorax ; and the infra-axillary, occupying the 
lower half of the lateral aspect of the chest ; at the back, the upper 
scapular, situated above the spine of the scapula; the lower scapular, 
corresponding to the infraspinatus fossa ; the inter-sccqyular, lying be- 
tween the vertebral border of the scapula and the spinous processes of 
the vertebras; and, lastly, the infra-sccqnilar, including all that part 
of the back of the chest situated below the lower angle of the scapula. 
We have not assigned exact limits to all of these regions, partly be- 
cause different writers assign different limits to them, partly because, 
convenient though they are for ordinary purposes, it seems to us pref- 
erable, when there is need of exactitude, to define the position and 
limits of area? by reference to the ribs and other fixed landmarks, and 
by measurement. 

Pathology of Voice, Respiration, Cough, and Expectoration. 

In the investigation of diseases, and more especially in the inves- 
tigation of those of the respiratory organs, much information may 
often be obtained by attention to any peculiarities which the voice or 
respiratory acts may present, to the presence or absence of cough, and 
the quality of the cough, and to the character of the expectoration. 

1. Voice. — The voice may be feeble, tremulous, or absent, its quality 
or its pitch may be changed, its register or compass may be contracted 
or modified, and, lastly, it may lose its musical character altogether 
and become hoarse. 

Mere feebleness of voice is so commonly associated* with the presence 
of diseases, whether in the lungs or elsewhere, which cause enfeeble- 
ment of the muscular system generally, that it attracts comparatively 
little notice. It essentially depends on feebleness or imperfection of 
the expiratory act, however these conditions may be brought about. 
Hence, we meet with it whenever there is much dyspnoea present, espe- 
cially if at the same time the respirations be hurried and shallow, and 
it is a notable characteristic of all cases in which, whether from disease 
of the spinal cord high up, or from any other cause, the diaphragm, or 
the intercostal muscles, or the muscles of expiration are paralyzed or 
weakened. The tremulous or bleating voice arises from want of accu- 
rate control over the expiratory muscles, or over those of the larynx 
itself. It is met with chiefly in old age and in persons who are hys- 
terical or nervous. 

Absence of voice, that is to say, total inability to produce laryngeal 
intonation, and the capability of evolving only that wheezy sound 



344 



DISEASES OF THE RESPIRATORY ORGANS. 



which forms the basis of all whispered vowels, indicates that the pa- 
tient is unable to bring the vocal cords into apposition, and that the 
riraa glottidis remains during his attempts at phonation in that patent 
condition which it affects during ordinary respiration. This condition 
is due to a paralytic state of the adductors of the vocal cords, which 
may be either of functional or of organic origin. 

The -pitch of the voice depends on the action of the larynx alone. 
There are two widely different diseases in which the voice very fre- 
quently becomes markedly high pitched or squeaky ; these are Asiatic 
cholera, and leprosy. It becomes high pitched also in those who are 
under the influence of laughing gas. Trousseau points out that, when 
there is lesion of the superior laryngeal nerve alone, there is, owing to 
the consequent paralysis of the crico-thyroid muscles, inability to utter 
the higher notes, and the voice consequently becomes deep-toned. He 
also points out that, in some forms of laryngeal inflammation, attended 
with hoarseness, the voice is low-toned on first rising, and becomes 
higher as the day advances. It is obvious that in this case the com- 
pass of the voice must be much diminished or altered. 

Pathological changes in the quality of the voice are largely dependent 
on conditions external to the larynx. It is thus that the quality be- 
comes altered when the faucial passage is narrowed by the presence of 
enlarged tonsils, when the soft palate is stiff and sore from inflamma- 
tion, or paralyzed after diphtheria, or when there is a cleft palate. 
Hoarseness or roughness of voice — 'in other words, loss or impairment 
of the musical quality of the voice — may depend upon any circum- 
stance which interferes with the regular vibration of one or both of the 
vocal cords. Thus it may arise from inflammatory or other thicken- 
ing of the cords, from ulceration, from the presence of warty or other 
growths, or from the adhesion of mucus or other matters to their sur- 
face, and it not unfrequently arises simply from the fact that, while 
one cord acts perfectly, the other cord is paralyzed. Hoarseness passes, 
on the one hand, into the normal intonation of the voice, on the other, 
into absolute aphonia. 

2. Respiration. — Ordinary quiet breathing is effected without appre- 
ciable effort, and with scarcely audible sound, at the rate, in the adult, 
of from sixteen to twenty respirations in the minute — their number 
having to the beats of the pulse a ratio of about one to four or five, 
and the act of inspiration being probably somewhat longer than that of 
expiration. The respiratory acts are liable in health, and still more in 
disease, to many deviations from the above rule ; they may be modified 
in frequency, modified in depth, modified in strength, and attended 
with more or less noise, discomfort, and effort. 

The frequency of respiration is diminished in syncope, and collapse, 
and various affections implicating the nervous centres, and occasionally 
also in cases of dyspnoea dependent on the presence of some mechanical 
obstacle to the entrance and escape of air. It is generally increased in 
inflammatory and febrile disorders, in affections of the lungs, pleurae, 
and heart, and above all, in some forms of hysteria, in which, indeed, 
the acts have been known to exceed one hundred in the minute. The 
depth of the respiratory acts is usually in inverse proportion to their 



PATHOLOGY OF COUGH. 



345 



frequency. Hence, when they are rapid, they are also, as a rule, shal- 
low and inefficient, when abnormally slow, they are deep and labored. 
Under these latter circumstances especially, the relative duration of 
inspiration and expiration is frequently considerably altered; in some 
cases, as, for example, in certain forms of gastrointestinal disturbance, 
and in some varieties of cardiac affections, the inspiratory acts are pro- 
longed and sighing; in others, and more especially in cases of emphy- 
sema, asthma, and mechanical obstruction of the larynx or trachea, 
the duration of expiration becomes relatively very largely increased. 
The respiratory rhythm is affected in another way in a variety of res- 
piration to which Dr. Stokes has called special attention, which only 
occurs in a marked form when death is impending, and chiefly, he 
thinks, in cases of enfeebled heart. It consists in the occurrence of a 
series of inspirations, increasing to a maximum, and then declining in 
force and length until a state of apparent apnoea is established. 

The term dyspnoea is employed of all cases in which respiration is 
unusually rapid, and equally of all those in which it is unusually slow, 
or even of normal rate, but attended with marked effort. The special 
muscular efforts which attend and indicate dyspnoea are in some cases 
apparently limited to the dilatation of the nares during each inspira- 
tion; in some to this act in conjunction with rhythmical opening of the 
mouth ; in other cases the muscles of the neck also act more or less 
powerfully ; and between these conditions and that which attends the 
asthmatic paroxysm, in which respiration is effected with the most 
agonizing efforts, and every ordinary and extraordinary muscle of 
respiration is called into powerful action, there are all gradations. The 
abnormal sounds which attend dyspnoea are sometimes a sniffing sound 
produced in the nares, sometimes a sucking or sipping sound manufac- 
tured with the lips, sometimes a panting sound effected in the throat. 

Further, whenever the rima glottidis is much narrowed, and in- 
capable of enlarging to permit the free passage of the breath, or when- 
ever the tube of the trachea is much diminished in calibre, as it may 
be from the presence in it of a diphtheritic membrane, or the pressure 
upon it of an aneurismal or other tumor, both inspiration and expira- 
tion acquire what is called a stridulous character ; they become pe- 
culiarly harsh and rough, presenting in some cases almost a metallic 
ring. These peculiarities are always greatly increased when respira- 
tion is hurried, or during the inspiration which precedes a cough. 
Closely related acoustically to stridor is wheezing or whistling, which 
is a common attendant on old bronchitis, and always accompanies the 
asthmatic paroxysm. 

3. Cough is a modification of breathing, characterized by a deep- 
drawn inspiration, followed by closure of the glottis and a series of 
short but violent expiratory acts. It is generally excited by some 
irritation or abnormal accumulation, either at the glottis, in the trachea, 
or in the larger bronchial tubes ; or it is a simple nervous affection. 
The act of coughing is generally preceded by tickling or some other 
uncomfortable sensation referable either to the larynx or some part of 
the trachea. The cough may be unattended with expectoration or dry, 
either because there is nothing to be expectorated, or because the 



346 



DISEASES OF THE RESPIRATORY ORGANS. 



offending matter cannot be dislodged, or it may be attended with more 
or less abundant discharge of mucus or some other matter. In the 
first case the cough may be that of the early or dry stage of inflamma- 
tion, or of hooping-cough, or it may be a nervous disorder. In the 
second case — that in which the cough is ineffectual — there is probably 
some mechanical obstacle to the discharge of peccant matter — some 
impediment in the larynx or trachea — or a limitation of the mucus to 
some of the smaller bronchial tubes, or clogging of the tubes with 
tenacious or even solid matter. The third case does not call for special 
remark. 

All coughs are from their very nature spasmodic ; but some, from 
the entire want of control which the patient has over them, and from 
peculiarities which they present, are especially deserving of that epi- 
thet. The most remarkable of these are the paroxysmal coughs which 
characterize pertussis, obstruction of the trachea, and spasmodic croup. 
In pertussis a deep inspiration is followed by a rapid succession of 
spasmodic expiratory efforts, continued until further expiration is 
mechanically impossible; then follows a long inspiration effected 
through the spasmodically closed glottis, and yielding the character- 
istic whoop. In spasmodic croup there is a series of coughs, the ex- 
pirations being remarkably harsh and noisy, the inspirations being 
attended with a whistling sound. In tracheal obstruction, the inspira- 
tions are prolonged, stridulous, and wheezing, the expirations also 
wheezy and often unattended with marked laryngeal noise, and these 
are repeated in rapid succession until the patient appears on the eve of 
suffocation, when probably he is relieved by the discharge of a little 
mucus. 

The noises which attend the act of coughing have already been 
partly considered. They may be divided into those which attend the 
inspiratory act and those which attend expiration. As regards the 
former, if there be spasmodic closure of the glottis, there is either a 
whoop, as in pertussis, or a whistle, as in spasmodic croup; but if the 
laryngeal orifice be obstructed by the presence of a false membrane 
upon it, or if there be an impediment in the trachea, the sound of in- 
spiration becomes wheezy or harsh. In the majority of cases the sound 
of inspiration is merely that of a deep-drawn breath. The sounds 
which attend the expiratory element of the cough are due to the condi- 
tion of the laryngeal orifice and to the force with which the expiratory 
blast bursts through it. Thus, if there be no impediment to the full 
inflation of the lungs, and if the vocal cords be in a normal condition, 
the expiratory acts will necessarily (if forcible) be more or less noisy 
and at the same time musical. But the character of the sound will of 
course be modified according to the degree of tension of the cords, and 
in some measure in accordance with the degree in which they may 
have become thickened or have lost elasticity in consequence of in- 
flammatory or other change. Many of the most noisy coughs are 
those which occur in hysterical or nervous patients, in whom the vocal 
cords are quite healthy in structure, and in those persons in whom 
they are affected with the slightest possible degree of inflammatory 
change. If, on the other hand, the vocal cords be prevented from 



PATHOLOGY OF EXPECTORATION. 



347 



vibrating freely, as may happen when the soft parts above the rima 
are greatly swollen, or when the cords and other parts of the larynx 
are invested with diphtheritic membrane, or when laryngeal or tracheal 
obstruction renders the expiratory blast extremely feeble, the cough 
loses its musical or sonorous character, and becomes wheezy and 
voiceless. 

4. Expectoration. — The expectoration is often a valuable aid to diag- 
nosis. Many persons, especially those beyond middle age, expectorate, 
on rising from bed in the morning, a small quantity of viscid or tena- 
cious mucus, studded with black particles. This black matter, which 
is supposed to be of extraneous origin, is nevertheless contained in cells. 
Such expectoration indicates the presence of a little bronchorrhoea, but 
is hardly to be regarded as a sign of any actual disease. In cases of 
inflammation of the respiratory passages, the discharge of mucus be- 
comes augmented, sometimes enormously. This at first is a watery, 
very slightly viscid, colorless fluid, of saline taste and reaction, contain- 
ing microscopically shed epithelial cells and mucous and granular cor- 
puscles. Later on its viscidity increases (sometimes it is very viscid 
from the beginning), it becomes difficult to void, and coalesces after ex- 
pectoration into a coherent mass, which adheres to the vessel into which 
it is discharged. Such expectoration is sometimes colorless, sometimes 
greenish or ygllowish, and occasionally streaked with blood. At a still 
later stage the sputa become opaque and yellow or green, less viscid, and 
acquire either the physical character of pus or characters between those 
of pus and those of typical mucus. This purulent conversion may be 
general or may affect the expectoration more or less unequally. Not 
unfrequently the sputa assume a nummulated aspect ; that is, pellets of 
pus-like character float in watery transparent mucus. All these varie- 
ties of expectoration may arise in the successive stages of either acute 
or chronic bronchitis — the presence of pure mucus alone indicating for 
the most part acuteness of inflammation ; that of pus, the supervention 
of a chronic condition, or possibly the approach of convalescence. The 
nummulated character implies that, while the bronchial tubes are partly 
secreting mucus, they are partly secreting pus, or pus is gaining an 
entrance into them from other sources. Nummulated expectoration is 
frequently met with in cases of dilated tubes, of pulmonary cavities, 
and of empyematous or other abscesses which communicate with the 
lung and discharge through it. It is, however, also met with in cases 
of simple chronic bronchitis. In many cases, when abscesses open into 
the lungs, the expectoration consists of almost pure pus. The expec- 
toration of ordinary acute pneumonia is characterized by extreme vis- 
cidity and more or less transparency, and by the fact that it is uniformly 
tinged with blood. The color which it thus acquires presents numer- 
ous gradations between yellow or reddish-brown (rusty) and a bright 
vermilion. As the disease passes into convalescence, the expectoration 
loses its peculiar color and its viscidity and becomes muco-purulent, 
like that of bronchitis. In certain cases it becomes either distinctly 
purulent, or, while still incorporated with blood, watery. The latter 
form of expectoration is sometimes likened to plum-juice. 

Blood in streaks occurs in bronchitis ; blood uniformly diffused in 



348 



DISEASES OF THE RESPIRATORY ORGANS. 



pneumonia ; but very often unmixed blood is poured into the bronchial 
tubes, and is discharged thence, either still unmixed or blended with a 
small quantity of mucus only. The sources of such pulmonary hemor- 
rhages are the bursting of aneurisms into the air-passages or lung- 
tissue ; the laying open of branches of the pulmonary artery or vein 
during the progress of tubercle, carcinoma, or other destructive morbid 
processes ; intense hyperemia of bronchial tubes or of the walls of pul- 
monary cavities, and pulmonary apoplexy. In the last group of cases 
the hemorrhage is generally scanty; in the others it is often extremely 
profuse. Copious and sudden hemoptysis is generally characterized by 
the arterial character of the expectorated blood, and by its more or less 
frothy condition ; but when the hemorrhage is small in amount, and 
expectorated at intervals only, it is often in the form of dark brownish 
or blackish-red pellets. 

It not unfrequently happens that casts of the air-passages are expec- 
torated. In diphtheria, membranous casts of various parts of the larynx, 
trachea, or larger bronchial tubes are often thus discharged. More 
rarely, branching casts of systems of the smaller bronchial tubes are 
from time to time expectorated. These are sometimes mere coagulated 
blood, sometimes simple pneumonic exudation concreted in the smaller 
bronchial tubes, sometimes casts of laminated texture, and apparently 
identical with diphtheritic membranes. 

Among the foreign bodies which are occasionally discharged from 
the lungs must be mentioned hydatids, either from the lung itself or 
from the liver, and earthy concretions, the remnants of dried-up tuber- 
cular matter in the lungs or bronchial glands. No doubt tubercular, 
carcinomatous and other such matters are occasionally expectorated, but 
they can very rarely be recognized as such. The progress, however, of 
destructive processes in the lungs may often be detected or verified by 
the discovery on microscopic examination of fragments of lung-tissue. 
A convenient way to discover these is to boil a measured quantity of 
sputum with a strong solution of caustic soda until they form a thin 
watery fluid, to place this in a conical glass for the purpose of subsid- 
ence, and then to examine the sediment microscopically. The matters 
to be especially looked for are the curved fragments of elastic tissue 
which bound the orifices of the smaller bronchial tubes, air-passages, 
and air-cells. 

Purulent expectoration has often a faint, sickly, or sweetish odor. 
The only smell, however, of clinical importance is that which is com- 
monly attributed to the presence of gangrene. This is horribly fetid, 
difficult to describe, but when once smelt impossible to forget. It may 
be readily detected in the sputum itself, but is evolved most intensely 
with the patient's breath during the act of coughing. The sputa which 
yield this odor are generally distinctly purulent, occasionally nummu- 
lated, and have usually a more or less discolored or dirty-looking 
aspect. Not unfrequently they are intermixed with blood in a more 
or less altered condition. 



INVESTIGATION BY SIGHT AND TOUCH. 



349 



Investigation by Sight and Touch. 

The information which may be acquired through the eye by inspec- 
tion, and through the hand by palpation, as to the condition of those 
functions of the respiratory system which lie within the scope of such 
methods of investigation, is obviously very considerable. We will 
speak of them in relation : first, to the larynx and trachea ; second, to 
the intrathoracic organs. 

1. Larynx and Trachea. Laryngoscope. — The apex of the epi- 
glottis may sometimes be seen, and its condition ascertained, by merely 
looking into the throat when the mouth is widely opened and the 
tongue depressed. Its condition and also that of the parts bounding 
the upper orifice of the larynx may sometimes, especially in children, 
be roughly yet sufficiently determined by means of the tip of the fore- 
finger passed back through the mouth into the fauces. The invention 
of the laryngoscope, however, and the perfection to which its use has 
been brought, make it now possible for us to determine the condition 
of the larynx with the utmost nicety, and to employ local remedial 
measures with intelligence and accuracy. The apparatus usually em- 
ployed for laryngoscopic examination comprise : first, a lamp yielding 
a steady, bright flame provided with some form of reflector or con- 
denser; second, a circular concave mirror, from 3 to 3J inches in 
diameter, and with a focal length of 12 or 14 inches, which should be 
freely movable in all directions upon its support, and should either be 
fixed to the forehead immediately above the eye by means of an elastic 
band, or attached to a spectacle frame and adapted to the right eye ; 
in the latter case it should be provided with a central perforation of an 
oval form ; third, a laryngeal mirror of metal or silvered glass, of cir- 
cular or quadrilateral form, and varying in diameter from half an inch, 
for a young child, up to an inch, fixed at an angle of about 120° to a 
thin metallic stem or shank, which should itself be fastened into an 
ivory or wooden handle. The entire length of the combined shank 
and handle should measure from 6 to 8 inches. In making an ex- 
amination, the patient should be seated in front of the examiner, with 
his head inclined a little backwards; the lamp should be placed at the 
side of, and somewhat behind, his head ; and the examiner should so 
arrange himself that his eye, with the mirror adapted, should be at the 
distance of about a foot in front of the patient's mouth. The mirror 
should be so adjusted as that the light which it reflects may be brought 
to a focus at about the back of the patient's uvula. He should then 
be directed to open his mouth widely and to protrude his tongue, the 
point of which should be firmly grasped and firmly but gently drawn 
forwards by the forefinger and thumb of the operator's left hand, en- 
veloped in a cambric handkerchief or towel. Then, the area of 
reflected light being steadily kept upon the point previously indicated, 
the laryngeal mirror (which has been previously warmed either over a 
lamp or by immersion in hot water, in order to prevent the conden- 
sation of the patient's breath upon it) is to be carefully passed back- 
ward until it reaches the base of the uvula, in which situation it must 
be held, with its surface facing downwards and forwards, at an angle of 



350 



DISEASES OE THE RESPIRATORY ORGANS. 



about 45° with the horizontal plane of the mouth. If the upper orifice 
of the larynx be not at once seen in the mirror, the direction of the 
face of the mirror may need a slight alteration, or it may be necessary 
to pass the mirror a little farther upwards and backwards, or otherwise 
to modify its position. It is important, in order that the examination 
be satisfactory : first, that both the patient and operator be patient and 
steady; second, that no needless force be employed to draw the tongue 
forward, and that it be not injured by undue pressure against the lower 
teeth ;. third, that in introducing the mirror, neither the tongue nor the 
palate be touched by it, excepting of course only that part of the palate 
against which it has to rest ; and, fourth, that no single introduction 
be of long duration. It is best, usually, to repeat the operation several 
times in the course of a sitting. It need scarcely be added that many 
difficulties present themselves to interfere with the success of laryngeal 
inspection, some of which render inspection impossible, while others 
may be overcome with a little patience and delicacy of manipulation. 

Even if the condition of the larynx be healthy, we may in some 
cases perceive only the epiglottis and the tips of the cornicula laryngis. 
In more successful observations, however, we may detect not only these 
bodies but all the other boundaries of the superior orifice of the larynx, 
including the aryteno-epiglottidean folds, the cartilages of Wrisberg, 
the posterior commissure, together with the rima glottidis, the true 
and false vocal cords, and, if the rima glottidis be open, sometimes the 
tracheal cartilages, and even the bifurcation of the trachea. All parts 
of the larynx, except the edge of the epiglottis and the true vocal 
cords, have a reddish hue, like that of the interior of the mouth, the 
gums, or lips, the redness being usually brightest in the false vocal 
cords, in the cushion of the epiglottis, and over the cornicula and car- 
tilages of Wrisberg. The vocal cords are pearly-white, the edge of the 
epiglottis, and, it may be added, the tracheal and the cricoid cartilages 
distinctly yellowish. 

It is always important to observe the movements of the vocal cords, 
and to examine the larynx both when the rima is fully open and when 
it is perfectly closed. The rima is always more or less widely open 
during ordinary quiet respiration ; but, in order to have it as widely 
open as possible, the patient should be directed to draw a deep breath. 
In order to effect closure, he should be required to utter a vocal sound. 
The best for this purpose, as requiring for their pronunciation the 
greatest expansion of the oral aperture and cavity, are the vowel sound 
which is sometimes termed "ur vocal," and is uttered in the words 
" cur " and "myrrh," and the broad sound of "a" represented by " ah." 

The morbid conditions for which we should mainly look are swelling, 
congestion, ulceration, and exudation, such as may be caused by various 
forms of inflammation, by diphtheria, syphilis, and other affections; 
warty or other kinds of growths ; various paralytic conditions, or con- 
ditions of spasm affecting the vocal cords; and, we may add, compres- 
sion of the trachea by aneurismal or other tumors. 

As regards the examination of the larynx and trachea from without, 
the chief points which are ascertainable are: first, the presence of ten- 
derness ; second, deviation of the trachea from the middle line, which 



INVESTIGATION BY SIGHT AND TOUCH. 



351 



may be due to tumors either in the neck or within the thorax; and, 
third, infiltration and thickening of the soft tissues. Thus, in inflam- 
matory affections of the larynx, especially in cases in which the carti- 
lages are in a state of necrosis, thickening with induration of the sur- 
rounding tissues is often a very remarkable feature ; and still more 
remarkable is the stony induration of parts and fixation of the larynx 
which attend some cases of carcinomatous infiltration. 

2. Chest. — The form of the chest is not unfrequently indicative of 
the presence of disease within it. It must not be forgotten, however, 
that its general form varies widely in different individuals, partly from 
inheritance, partly from rickety tendency during early life; and that 
want of symmetry is often traceable to the excessive use of the right 
hand, or to spinal curvature. But such varieties are quite independent 
of pulmonary affections, and we must be careful not to confuse them 
with those which are attributable to the latter causes. 

General expansion of the chest is a common characteristic of patients 
who have suffered for many years from chronic bronchitis or asthma, 
especially if there be at the same time pulmonary emphysema. Partly 
in consequence of long-continued over-exertion of the inspiratory mus- 
cles, partly from the difficulty which emphysematous lungs have of 
getting rid of their surplus air, the chest becomes increased in both its 
antero-posterior and lateral dimensions, and assumes a rounded or 
barrel-like form. If such changes commence in the chest during early 
infancy, it is not unusual to find that, while the upper part of the chest 
has become generally expanded, the lower zone has (owing to the com- 
parative weakness of the ribs in early life) become in a greater or less 
degree contracted. It is not common for the causes here spoken of to 
operate on one side of the chest only. General enlargement of one side 
may be caused by accumulation of serum, pus, or air in the pleural 
cavity. In such cases, the intercostal spaces become widened, the inter- 
costal depressions effaced, and in some instances (especially in cases of 
inflammation) replaced by actual bulging. In some cases of fluid accu- 
mulation, undulation or fluctuation may be detected. In cases in which a 
lung is wholly or in the greater part of its extent pneumonic, the affected 
side remains fixed in the position of full inflation. Localized enlarge- 
ments, or bnlgings, may be the result of localized accumulations of air 
or fluid, or of the presence of aneurismal, sarcomatous, or other varieties 
of intrathoracic tumors. In cases of empyema, it is not uncommon for 
the pus to find its way between the ribs, to form an accumulation be- 
tween them and the integuments, and thus to cause a localized swelling. 

Contraction of the thoracic walls is exceedingly common; it is rarely, 
however, general and symmetrical. It is generally either unilateral 
or limited to definite regions. All pulmonary diseases attended with 
diminution in the size of the lung, are attended with more or less 
marked contraction corresponding to that diminution. The most 
remarkable degree of contraction is that which so often follows on 
empyema or hydrothorax which has caused complete and permanent 
collapse of the lung. With the absorption or removal of the fluid the 
affected side becomes reduced in all its dimensions, and the patient's 
carriage comes to resemble that of a person suffering from lateral cur- 



352 



DISEASES OF THE RESPIRATORY ORGANS. 



vature of the spine. Atelectasis, apneumatosis, cirrhosis, and the con- 
traction of cavities are all attended with more or less manifest contrac- 
tion of that area of the chest-walls which corresponds to the portion of 
the lung involved. The most frequent, and on the whole the most 
important of these localized contractions is that which is so commonly 
observed beneath one or both clavicles during the progress of phthisis. 

The movements of the chest are often very significant. The violent 
muscular efforts, yet little movement of the ribs, which mark the respi- 
ratory act of emphysematous patients with barrel-shaped chests is very 
characteristic. The entire quiescence or little comparative movement 
which occurs on the affected side of the chest in cases of effusion into 
the pleura or of consolidation of the lung, or which is observable at 
the apex of the lung in cases of phthisis, is equally matter of interest 
and of clinical importance. 

Whenever grave notes are uttered by the voice a distinct vibratile 
thrill, the vocal fremitus, may be felt not only over the larynx and 
trachea, but over the face and head and over the whole of the surface 
of the chest to which lung-tissue is subjacent. The best mode of de- 
tecting this thrill is to place the palm of the hand flat and firmly on 
the part of the chest selected for examination. The degree in which 
it may be perceptible varies greatly in different persons, in dependence 
partly on the pitch and strength of the voice, partly on the quantity 
of muscle or fat present in the parietes of the chest. It is generally 
most easily recognized in male adults with spare frames. For obvious 
reasons it is more perceptible at the upper part of the chest, in front 
and between the scapulae, than elsewhere; and it is either absent from 
the area of cardiac clulness, or comparatively feeble there. It is said 
by some to be a little more marked on the right than on the left side 
of the chest, but the difference at most is trivial ; and it may be regarded 
as a general rule that, with the exceptions already mentioned, it is pres- 
ent in an equal degree at corresponding parts of the two sides of the 
chest. The presence of disease very largely modifies the vocal fremitus. 
Whenever there is fluid effusion into the chest, the thrill becomes greatly 
enfeebled or absolutely annulled over the surface to which the fluid is 
subjacent. Whenever, on the other hand, lung-tissue is consolidated 
by pneumonia, the vocal fremitus over the affected region becomes 
largely intensified. It must be added that merely thickened pleura, or 
accumulation of solid lymph in its cavity, acts equally with fluid pleural 
effusion in damping vocal fremitus ; that solid growths, whether in the 
lung or external to it, have a like effect; and that in rare cases fremitus 
is diminished even over pneumonic lung. The explanation of the 
diminution of vocal fremitus in the several cases of such diminution 
above enumerated is sufficiently obvious. The intensification which 
attends most cases of pneumonia is due apparently to the concurrence 
of two conditions, — the one consolidation of the vesicular tissue which 
increases its capability of conducting sounds ; the other the permeation 
of the solid mass by pervious tubes along which the vocal vibrations 
are carried into its midst. 

In support or correction of the judgments formed from the results 
of visual or manual examination, it is always well to have recourse to 



PERCUSSION AND AUSCULTATION. 



353 



actual measurement of the chest or of portions of it, and of the amount 
of expansion or movement which they undergo. It is needless to de- 
scribe in detail how such measurements are to be effected ; it is suffi- 
cient, probably, to name the chief instruments which may be used for 
the purpose, namely, the measuring-tape and calipers. 

Investigation by Percussion and Auscultation. 

Of all aids to the recognition of the morbid processes which are 
going on within the thorax none is so important as the employment of 
percussion and auscultation — both methods of investigation scarcely 
thought of prior to the commencement of the present century, but 
which within the last fifty years, have been largely cultivated and 
have furnished the most valuable results both to the physiologist and 
the physician. 

1. By percussion is meant the investigation of the condition of the 
internal organs by the sounds which are yielded by sharply striking 
the surfaces to which they are subjacent. There are three principal 
methods by which this may be effected, namely : 1st, by striking the 
surface directly either with the fist, the knuckles, or the tips of two or 
three fingers brought together into the form of a hammer; 2d, by the 
use of the hammer and pleximeter — the pleximeter is a small thin ivory 
disk which, for the purpose of receiving the blow of the hammer, has 
to be laid firmly and flat upon the surface of the part to be percussed ; 
the hammer, which usually has a comparatively heavy metallic head, 
is furnished at its striking extremity with an india-rubber pad, which 
alone comes in contact with the pleximeter, and prevents the develop- 
ment of any sound special to the instrument; 3d, by the employment 
of the fore or middle finger of the left hand as a pleximeter, and of the 
tips of one, two, or three fingers of the right hand as a hammer; in 
this case the finger of the left hand should be laid firmly and flat, with 
its palmar surface downwards, on the surface to be examined, and the 
tips of the striking fingers of the opposite hand should be brought 
down perpendicularly and sharply upon it. The first of these three 
methods of percussion has fallen into almost entire disuse, chiefly be- 
cause of the needless pain which it is so apt to inflict. The second 
method is a valuable one, especially for clinical teaching, because the 
sounds which it evolves are loud and may readily be distinguished by 
a class of students. The third method is that which is in general use, 
partly because of its great convenience, and partly because, although 
the sounds which are elicited by it are comparatively feeble, they are 
perfectly appreciable. It may be noted here that, whenever it is sought 
to compare by percussion the corresponding parts of opposite sides of 
the trunk, it is most important that for each pair of examinations the 
pleximeter, wdiether the finger or the disk, should be symmetrically 
placed, and the force and direction of the blows should correspond ; 
and, further, that it is important as far as possible to prevent any sound 
due to the instrument itself from interfering with that elicited from the 
part percussed. 

23 



354 



DISEASES OF THE RESPIRATORY ORGANS. 



Normal Percussion Phenomena. — The sounds which are yielded to 
percussion by the healthy chest are of two kinds, resonant and dull. 
These words are by no means well chosen, but they are sanctified by 
long and general usage, and would be difficult to replace. By reso- 
nance we mean to imply the presence of more or less musical quality, 
by dulness the absence of all such quality. 

a. Resonance. — A resonant sound is yielded by all those portions of 
the chest-walls which are by their deep aspect in contact with lung, and 
by that part of the left half of the chest to which the stomach is sub- 
jacent. The quality of the resonant sound which is evolved on per- 
cussing the pulmonary regions of the thorax is difficult to describe, 
but sufficiently characteristic to be easy of recognition when once it has 
been heard. It is somewhat deep in tone, short in duration, and vaguely 
musical. It differs, however, in quality in some degree in different parts 
of the chest, and considerably in different individuals. Hence it is 
important, in judging of the significance of percussion-sounds, not to 
assume the existence of a normal standard sound with which all others 
must be compared, not even to compare the resonance of one person's 
chest with that of another, nor, indeed, to compare indiscriminately 
the resonance of different parts of the same individual's chest. But 
we should carefully compare the sounds yielded by the corresponding 
points of the two sides of the chest. The chief cause of the resonant 
quality of the percussion-note is the vibration of the struck walls, which 
is permitted by the fact that an elastic medium, the air, is situated on 
either side of them. It is obvious, however, that the elasticity of the 
inflated lungs is less than that of the free atmosphere outside, and that 
hence the vibration of the thoracic walls must be to some extent less 
perfect than it would be were the air on both sides equally free to 
move. The sound, we repeat, is mainly due to the vibration of the 
thoracic walls alone; but it is difficult (owing to the somewhat irregu- 
lar form and structure of these walls, and to the interference with their 
vibration caused, on the one hand, by the solid organs which lie here 
and there beneath them, and, on the other hand, by the junctions of the 
chest with the upper extremities) to determine to what extent and in 
what manner these vibrations are effected. It seems reasonable, how- 
ever, to assume that so much of each half of the thorax as bounds lung- 
tissue vibrates bell-like when any part of that half is struck, and that 
the impure musical sound which is elicited comprises a fundamental 
note due to the vibration of the whole or a large portion of the side, 
and harmonic tones due to the vibration of aliquot parts of it. This 
view is entirely compatible with the fact that percussion-notes of some- 
what different quality are yielded on striking different parts of the 
surface, and, if correct, makes it obvious that the sound elicited by the 
percussion of any spot is by no means necessarily indicative of the 
condition of the lung-tissue immediately beneath it. It must be added 
that some, though a very variable, quantity of thoracic resonance is 
independent of the presence of air beneath the chest-walls. Thin and 
elastic bones, even if they be imbedded in solid tissue, vibrate sensibly 
when percussed. A sound which is not absolutely dull may be obtained 1 
by percussing the bones of the skull ; and some degree of resonance 



PERCUSSION. 



355 



may always be elicited over the sternum even when no lung-tissue is 
subjacent to it. The ribs, also, especially if the patient be thin, usually 
yield a somewhat resonant sound. 

The stomachal resonance may always be recognized (though variable 
in extent, distinctness, and quality, according to the degree of disten- 
sion of the organ with gas and to the level which it attains within the 
cavity of the thorax) at the lower part of the left side of the chest, both 
posteriorly, laterally, and in front, but chiefly in the last two situa- 
tions. It may readily be distinguished from the normal lung-reso- 
nance by its much more distinctly musical character, by its purer tone 
and generally higher pitch. The sound in consequence is often termed 
tympanitic, or drum-like. 

b. Dulness. — Absence of resonance, or dulness, is observable on per- 
cussing the precordial region, and also on percussing that portion of 
the lower part of the right side of the chest between which and the 
liver no lung-tissue intrudes. This sound, again, can be better appre- 
ciated by a single experiment than by any description. It may be 
described as short, somewhat sharp, and unattended with any appre- 
ciable ring or tone. The feeble sound elicited by the percussion of the 
thigh is often referred to as the very type of a so-called "dull" sound. 
It differs, however, materially from that which is yielded by the pre- 
cordial region. And, indeed, the quality of dulness, in the clinical 
sense, presents many varieties, and passes by insensible gradations into 
that of resonance. Many so-called dull sounds become obviously 
musical when tested stethoscopically. 

Abnormal Percussion Phenomena. — Percussion in cases of pulmonary 
disease is mainly of use in enabling us to ascertain the presence and 
define the limits of consolidation, or of pleural effusion, or of morbid 
growths. 

a. Dulness. — Whenever any considerable mass of lung-tissue is ren- 
dered solid, either by tubercular infiltration, by inflammatory deposit, 
by effusion of blood, by carcinomatous growth, or in any other way, 
all that area of the chest-wall on which it abuts loses its normal reso- 
nance and becomes more or less dull. The presence of fluid in the 
pleura causes dulness in even a more marked degree up to the level of 
the effusion. The recognition of the cause of dulness must depend 
partly on the situation, extent, and form of the area of dulness, partly 
on a variety of considerations, the collective significance of which will 
be more conveniently discussed hereafter. It may be mentioned, how- 
ever, that pneumonic consolidation usually occurs in the lower part of 
the lung, tubercular infiltration at the apex, and that pleuritic effusion, 
unless it be circumscribed by adhesions, or so abundant as entirely to 
compress the lung, may often be recognized by the changing level of 
the upper limit of dulness in accordance with the different positions 
which the patient's trunk may be made to assume. But although 
marked dulness is always present when consolidation is extensive and 
continuous, it is often absent, or at all events scarcely appreciable, 
either when an extensive tract of lung-tissue uniformly contains more 
solid matter or fluid and less air than natural, or when miliary or 



356 



DISEASES OF THE RESPIRATORY ORGANS. 



larger nodules of solid tissue, separated from one another by a network 
of crepitant tissue, are even thickly distributed. Thus congested or 
(Edematous lungs, and lungs in the early stage of inflammation, on the 
one hand, and lungs which are the seat of disseminated tubercles or 
of lobular pneumonia on the other, are not un frequently so strikingly 
resonant as utterly to deceive the too confiding percussor. 

b. Resonance. — It is obvious that, whenever there is any extension 
of the area of dulness, there must be a corresponding diminution in 
the area of resonance. On the other hand, the normal arese of thoracic 
dulness are not very unfrequently reduced or effaced by the extension 
of resonance. In association with such changes, and sometimes indeed 
apart from them, the resonance of the resonant area is altered in inten- 
sity, in quality, or in pitch. To denote different varieties and degrees 
of resonance many terms have been employed — such, for example, as 
wooden, leather-trunk-like, tubular, cavernous, tympanitic, high- 
pitched, and the like. Some of these are obviously fanciful, some indic- 
ative of a foregone conclusion with regard to the case under examina- 
tion ; but others do, to some extent, explain themselves, are applicable 
and convenient. Augmentation of resonance (to which condition the 
epithet tympanitic is sometimes given) may often be heard over emphy- 
sematous lungs, or over lungs distended (as they sometimes are in 
cases of acute bronchitis) with air, but especially over a pleural cavity 
the seat of pneumothorax. It should be added, however, that in such 
cases the augmentation of resonance is for the most part attended with 
the production of a purer note, and for the most part a note of some- 
what higher pitch than characterizes the normal chest-resonance of the 
patient. But augmented resonance, with change of quality and pitch, 
is often heard under very different conditions from those which have 
just been considered. It is frequently observed, for example, that in 
cases of extensive pulmonary consolidation, or pleural effusion of one 
side, the crepitant remnant of lung-tissue evolves under percussion a 
much purer note than the corresponding part of the opposite lung. 
The sound is sometimes described as being more resonant than that 
yielded by the opposite side; possibly it may be so, but it is at all 
events more distinctly musical, and always of considerably heightened 
pitch. Not unfrequently indeed the sound is almost exactly like that 
produced by percussing a portion of small intestine or by striking one 
of the treble keys of the piano. This modified resonance is most fre- 
quently observed over the apex of the lung when the rest of the organ 
is consolidated or compressed, but by no means necessarily occurs only 
in that region. And it must be added that similar high-pitched reso- 
nance may sometimes be distinctly heard over portions of pneumonic 
lung which have not yet become completely solidified. Various ex- 
planations of the phenomena here described have been given. With 
respect to the increased resonance which attends pneumothorax, em- , 
physema, and the like, it will probably be admitted that it is due to 
the more ready and perfect vibration of the thoracic walls which the 
relative increase of air beneath their inner surface permits. This ex- 
planation will, however, scarcely apply to the higher pitch which the 
percussion-note usually then acquires, and is certainly not applicable 



PERCUSSION. 



357 



to those cases in which high-pitched resonance occurs over partly con- 
solidated lung, or over lung in the neighborhood of consolidated tissue. 
Reverting to the explanation we have already given of the ordinary 
resonant sound yielded by the thoracic walls (namely, that in its pro- 
duction all those portions of the thoracic walls which are in contact 
with the lung under examination vibrate, bell-like, producing a some- 
what obscure assemblage of fundamental and harmonic tones, the gen- 
eral effect of which is deep in some sort of proportion to the extent of 
surface which vibrates) ; and knowing that (other things being equal) 
the smaller a vibrating area becomes the higher will be the funda- 
mental tone it yields; and seeing that such a diminution of vibrating 
area necessarily takes place when there is extensive consolidation or 
fluid effusion, and not improbably occurs in the first stage of pneu- 
monia over the affected portion of lung ; it seems reasonable to assume 
that in these considerations mainly is to be sought the explanation of 
the acoustic phenomenon in question. It must not be forgotten, how- 
ever, that the increase of tension which in pneumothorax, and in a less 
degree in pleurisy with effusion, the thoracic walls experience, also 
tends to the production of a higher note. 

The question " how far can the percussion-note be modified by con- 
ditions within the chest other than those which have been discussed?" 
still remains for consideration. Can it, for example, be affected by 
the neighborhood of solid matter separated from the parietes by a 
layer of crepitant tissue? Can it be modified by the internal resonance 
of cavities which abut upon the surface? The former of these ques- 
tions has been answered in the affirmative by most writers, who assert 
that, by regulating the force of the percussion-stroke, the resonance 
due to the intervening lung and the d illness due to the subjacent solid 
structure, can be distinguished, and that thus the extension of the 
heart beneath the thin edge of the lung, and the ascent of the liver 
behind the lower margin of the right lung, can be easily detected. 
We confess we are not satisfied of the truth of this assertion. As to 
the latter of these questions, there is no doubt, that if auscultation be 
practiced at the same time as percussion, the resonance due to a sub- 
jacent large cavity may occasionally be recognized in the form of a 
superadded musical twang. There is, however, one variety of percus- 
sion-sound which certainly owes its peculiarity to the conjunction of a 
sound produced within the chest, with that due to the vibration of the 
thoracic walls, namely, the bruit de pot fele, or cracked-pot sound, a 
sound which may be almost exactly simulated by clasping the hands 
crosswise, and then striking the back of one of them sharply against 
the knee-cap. The " chink" which distinguishes it appears to be due 
to the sudden compression of a portion of lung-tissue and the sharp 
expulsion of the air which it contained with an audible hiss through 
the bronchial tubes. To produce the sound the percussion-stroke 
must be forcible, and made while the patient is expiring with his 
mouth open. It is chiefly producible in the front of the chest, either 
at the apex or in the mammary region. It may indicate the presence 
of a cavity in the lung, but is more commonly produced in the healthy 
chests of young children, owing to the great yieldingness of their thin 



358 



DISEASES OF THE RESPIRATORY ORGANS. 



thoracic parietes, and in patients suffering from pneumonia or pleurisy 
in association with the high-pitched resonance so often present. 

c. Resistance. — One further indication of importance often furnished 
by percussion is the presence of unyieldingness or resistance. In the 
percussion of healthy chests the resilience of the parietes can always be 
in some degree appreciated ; it is indeed so constant and so essential a 
factor of the process that on that very account it may escape observa- 
tion. But in cases of solid growths in the cavity of the thorax, and in 
cases even of pleurisy with much thickening of pleura and much dis- 
tension, the rigidity of the thoracic walls over some limited area, and 
their total want of elasticity and of yieldingness are quite remarkable 
and unmistakable. 

2. By auscultation is meant the process of listening, either by directly 
applying the ear to the surface, or by the aid of some conductor, to 
sounds evolved within the body. The direct application of the ear 
to the surface is in some respects preferable to any other mode of aus- 
cultation. Many sounds are thus heard much more distinctly than 
they otherwise would be heard; and some delicate but distinctive 
sounds are wholly lost in their passage along a conducting rod or 
tube. But, on the other hand, the naked ear cannot be applied with 
ease to all parts which it is desirable to auscultate, nor can we by its 
aid limit our examination with precision to minute arese. The objec- 
tions on the score of delicacy and cleanliness are sufficiently obvious. 

The Stethoscope. — The instrument which is employed to convey sounds 
produced within the body to the ear of the observer is termed the 
" stethoscope." Of this innumerable forms and varieties have been 
invented and are in use. As to material, they have been made of bone, 
ivory, silver, gun-metal, gutta-percha, and different kinds of wood ; as 
to form, they are always cylindrical in the whole or greater part of 
their extent — in the latter case being provided at one end with a cir- 
cular disk to fit the ear, at the other end with a conical expansion, the 
circular base of which is to be applied to the part under examination. 
Further, they are made of different lengths, sometimes solid throughout, 
but generally with a cylindrical channel running through the stem from 
the ear-piece downwards to the conical enlargement, where it undergoes 
a corresponding dilatation. The material, the length, and the general 
form of the instrument are matters of very little real importance. The 
great desiderata are that it should be light and portable, that the ear- 
piece should be one that readily adapts itself to the ear of its possessor, 
and that the conical enlargement at the opposite end should be of me- 
dium size, and that (if provided with an opening) its margin should 
be sufficiently broad and rounded to admit of its adjustment without 
causing pain. 

There are certain peculiarities in the acoustic properties of stetho- 
scopes which it is well to be aware of. Solid stethoscopes undoubtedly 
convey sharp impulsive sounds and musical notes with great intensity ; 
but they do not transmit the respiratory rustles and other feeble and 
unmusical sounds with anything like the distinctness with which the 
hollow stethoscope conveys them. The difference is very much that 
existing between a speaking-tube which readily transmits the whispered 



AUSCULTATION. 



359 



voice, and a solid rod which, with the aid of a sounding-board, repro- 
duces at a distance the full music of a piano with which its opposite 
extremity is in contact. The hollow stethoscope, however, combines 
in itself the properties of both, and is therefore the preferable instru- 
ment for common use. Again, it is indisputable that certain sounds 
are much more distinctly audible with some hollow stethoscopes than 
with others; and that this fact is, in some instances, at all events, due 
to differences in the length of the instruments. The explanation of 
the phenomenon appears to be that the tubes of stethoscopes consonate, 
according to their length, with certain definite notes and certain of their 
harmonics. 

Besides the simple varieties of stethoscope above considered, there 
are two others which are often of considerable service. These are the 
binaural and the differential stethoscopes. In the former the stem 
arising from the conical end divides into two branches, the points of 
which respectively fit into either ear. Both ears are thus equally 
engaged in listening to the sounds emanating from the area under ex- 
amination, which are hence intensified, and on the whole more easily 
appreciated. The other form of stethoscope is also binaural in the 
sense that there is an ear-piece for each ear, and both ears are engaged ; 
but the tubes which are prolonged from the ear-pieces remain distinct 
from one another and terminate each in a conical expansion. The 
advantage of this arrangement is that by it the auscultator is enabled 
to hear and determine the synchronism or asynchronism of sounds 
which are developed at different spots. 

In using the stethoscope, it is of essential importance that (if it be 
hollow) its lower end should rest evenly on the surface to which it is 
applied, that the ear-piece should be adjusted accurately to the ear, that 
nothing whatever should be in contact with the instrument save the ear 
of the auscultator and the surface under examination, and that there 
should be no rustling or friction or other noises in connection with the 
patient's skin or clothes. It is always best to listen to the naked skin ; 
and, if covering be necessary, it should be as thin as possible and in one 
layer only. Further, it is sometimes well to close the opposite ear 
against extraneous sounds. 

Normal Auscultatory Phenomena. — The normal sounds which may 
be heard by means of the stethoscope applied over the respiratory 
organs are those due to respiration and those produced by the acts of 
articulation and phonation. In morbid conditions of these organs, the 
acoustic phenomena attending the several acts referred to become vari- 
ously and largely modified, and others of a totally different class may 
be superadded. 

a. Auscultation of the Breath. — If we apply the stethoscope to the 
larynx or trachea during ordinary respiration, a somewhat harsh, blow- 
ing sound is heard to accompany both the act of inspiration and that of 
expiration. The sound is like that of the loudly-whispered vowel 
represented by the syllable "ur," or' like the whispered consonantal 
sound of the letter w. Each sound lasts as long as the act which pro- 
duces it, is uniform in character throughout, begins and ends abruptly, 



3l>0 



DISEASES OF THE RESPIRATORY ORGANS. 



and is separated by an obvious though very short interval from the 
sound which follows it. That which attends inspiration is somewhat 
sharper and louder than the other, and both maybe increased or dimin- 
ished in intensity by varying the force of the respiratory movements. 
The sounds are almost certainly developed at the narrowest part of the 
tube, namely, the rima glottidis, by the rustle which its interference 
causes in the current of air passing through it. The slight but obvi- 
ous differences in quality and force which distinguish them from one 
another are hence explicable, the sound produced at the rima being 
carried inwards with the inspiratory current, outwards during expira- 
tion. Ordinarily, the sound attending expiration is more audible to 
oneself and to bystanders than that attending inspiration. The sounds 
here described, though somewhat modified in character, are in general 
still audible over the manubrium of the sternum, and between the 
scapulae, at and above the level of the roots of the lungs. 

Over the lungs themselves the sounds which attend the respiratory 
movements are of a very different character from the above. The in- 
spiratory sound is difficult to describe. It has a kind of rustling char- 
acter, and is feebler and of lower pitch than the corresponding tracheal 
murmur; the expiratory sound is often absent, and when present, is 
still feebler and lower in tone than the inspiratory sound. Moreover, 
the two sounds, instead of presenting uniform intensity throughout, 
and being separated by a distinct interval from one another, commence 
and die away so gradually that they seem like mere pulses of a con- 
tinuous murmur. The healthy pulmonary sounds vary a good deal 
in intensity, and, in some degree, in quality in different individuals ; 
there are also slight differences between those heard at different parts of 
the same chest. And not unfrequently, especially at the apex, the sound 
towards the end of a deep inspiration assumes an indistinctly crepitat- 
ing character. What is the cause of these sounds? That they are not 
simply made in the larger air-passages, and conveyed through the 
spongy tissue of the lungs to the surface, seems clear, from the fact 
that, in those cases where, from contraction of the larynx, trachea, or 
bronchial tubes (laryngitis, pressure of an aneurism, and asthma, to 
wit), a peculiarly intense noise is made in these canals during respira- 
tion, the pulmonary murmurs, instead of being correspondingly aug- 
mented, are diminished or actually annulled. The* ordinary explana- 
tion is doubtless the correct one, namely, that they are produced in the 
minuter air-passages and air-cells by the passage of air to and fro in 
them, and by the changes of form — the movements — -which these parts 
undergo. 

b. In auscultating the voice, it is important to recollect the fact that 
phonation takes place — the music of the voice is manufactured — at the 
rima glottidis by the vocal cords; that articulate sounds are formed 
only in the cavity of the mouth, by means, chiefly, of the lips, tongue, 
and palate. If the larynx or trachea be examined stethoscopically 
during the act of speaking aloud or singing, the musical notes which 
are evolved are conveyed through the instrument to the ear with 
almost painful force; similar sounds, diminished somewhat in inten- 
sity, are audible also over the manubrium of the sternum, and between 



AUSCULTATION. 



361 



the upper parts of the scapulae behind. They are still audible, but 
with very much less force, over the whole of those portions of the 
chest which have lung-tissue subjacent to them. The sounds are 
usually somewhat more intense above than below, in front than 
behind, and at the lower part, posteriorly, sometimes present, even in 
health, a somewhat bleating character. The degree in which vocal 
resonance, or bronchophony, is audible, varies, in different individuals, 
chiefly in dependence on the pitch and quality of the voice. Thus it 
is, as a rule, more obvious in those who have a deep voice than in 
those whose voice is high, and is more obvious, therefore, in men than 
in women or children. It may be added that it is often distinct when 
vocal fremitus is quite imperceptible, and that in some individuals it 
scarcely exists at all. The articulate voice is always best distinguished 
when the patient speaks in a whisper; words thus uttered are dis- 
tinctly transmitted through the stethoscope applied to the windpipe in 
the neck, or along its course in the thorax, or over the situation of the 
bronchi ; they may also be occasionally heard over the apices of the 
lungs of healthy persons, especially children. This phenomenon is 
termed pectoriloquy. 

Abnormal Auscultatory Phenomena. — The respiratory sounds are 
often much modified in disease. We have adverted to the fact that 
they are frequently not only greatly diminished, but actually absent in 
certain cases of obstructive disease, of the larger air-passages ; they are 
enfeebled also whenever the respiratory movements are themselves 
feeble, and are often much weakened or annulled where the lung is 
compressed, or consolidated, or displaced, or where fluid, or air, or solid 
matter lies between it and the thoracic walls. On the other hand, the 
respiratory sounds are necessarily intensified whenever the acts which 
produce them are unusually vigorous. It is due to this cause alone, 
doubtless, that they may be often heard with preternatural loudness 
over the healthy lung of a patient whose other lung is pneumonic, or 
compressed by pleural effusion. 

a. Tubular or bronchial breathing is a modification of respiratory 
sound very frequently heard in lungs consolidated by pneumonia, 
compressed by pleuritic effusion, or containing smallish cavities, of 
whatever origin, imbedded in airless tissue. It almost exactly resem- 
bles the breath-sounds which are audible over the trachea. The in- 
spiratory and expiratory elements begin and end abruptly, are uniform 
throughout, and separated from one another by a distinct but short 
interval. They vary in quality in different cases and under different 
circumstances, but are generally higher in pitch than the tracheal 
sounds are ; moreover the expiratory sound is, as in the case of the 
tracheal, somewhat deeper and less distinct than that of inspiration. 
It is necessary, in order to their full development, that the respiratory 
acts be moderately forcible, that the air-tubes of the portion of lung 
under examination be not completely obstructed, and do not contain 
mucus or other matters in their interior which are productive of crepi- 
tating and other such adventitious sounds. Hence, in pneumonia, 
tubular breathing may be absent or incapable of recognition if the tubes 



362 



DISEASES OF THE RESPIRATORY ORGANS. 



I 



be blocked up with casts, in pleurisy, if the compression of the lung 
be so great as to involve the obliteration of the tubes, in cases of pul- 
monary cavities, if the cavities have no free connection with the air- 
channels, and in all such affections when the cavities or channels are 
loaded with mucus or other fluids. Various explanations have been 
offered of the production of tubular breathing. By some it has been 
considered that the sounds heard over the affected portion of the lung 
are simply those manufactured at the rima glottidis, conducted to the 
ear through the diseased tissues. Others consider that the tubular 
sounds are actually produced by the to-and-fro movement of air in the 
tubes of the diseased tract, while others again, with Skoda at their 
head, regard them as the laryngeal sounds increased and modified by 
consonance in the bronchial tubes. An insuperable objection, it seems 
to us, to the truth of Skoda's explanation, is the fact that consonance 
either increases the intensity of obvious musical tones, or else develops 
an obvious musical tone from vibrations which are musical in rhythm, 
but are of themselves too feeble for the ear distinctly to appreciate. 
But the tubular sounds heard over a pneumonic lung are no more mu- 
sical than those heard over the trachea. An objection to the second 
explanation resides in the fact that, in the majority of cases in which 
tubular breathing is heard, the affected lung-tissue neither expands nor 
contracts during respiration, so that there can be no to-and-fro move- 
ment of the air in its tubes to cause the sounds which may be heard 
over it. The first explanation appears to us to be substantially cor- 
rect, for the following reasons: The sounds of tubular breathing are 
like those which are produced at the rima glottidis during respiration; 
there is no doubt whatever that these, as well as all other sounds de- 
veloped at this orifice, are readily conveyed, with little change of char- 
acter, along the patent bronchial tubes, as along so many small stetho- 
scopes, towards their peripheral distribution; the intensity of the tubular 
sound is proportionate, in great measure, to the intensity of the laryn- 
geal sound — and, indeed, a distinctly tubular sound may, even in 
health, be developed and actually overpower the normal respiratory 
sounds when patients who are told to breathe deeply breathe noisily 
through the larynx. We are by no means prepared to deny that to- 
and-fro sounds, differing little from those originating in the larynx, 
maybe produced by the to-and-fro movement of air in bronchial tubes 
connected with lung capable of respiration, and that such sounds may 
contribute in some cases to the collective result which we term tubular 
breathing. Whatever explanation be adopted, however, there is no 
doubt that the homogeneousness of texture which a consolidated or 
compressed lung presents allows, far more readily than normal spongy 
lung-tissue does, of the transmission of sounds which are developed 
within or conveyed into its substance, and further, that the total sup- 
pression of the healthy respiratory murmur which characterizes all 
those conditions of lung in which tubular breathing is heard, con- 
tributes importantly to its ready recognition. 

b. Amjihoric, Cavernous, or Metallic Breathing. — These terms are 
employed to designate the peculiar quality of sound which may be 
sometimes heard over cavities containing air, and usually communi- 



AUSCULTATION. 



363 



eating with the external atmosphere by means of the bronchial tubes 
or other passages. It consists in a peculiar metallic ring, or musical 
twang, following upon the respiratory or other sound which calls it 
forth. A closely similar twang attends the footfall of a person walking 
between high walls, or over a vault, and may be recognized in perfec- 
tion if a child's india-rubber ball be placed in contact with the ear and 
then sharply tapped or filliped. The addition to any other intrathor- 
acic sound of the musical prolongation here referred to is always 
indicative of the presence of a cavity containing air ; and it may be 
sometimes heard almost as distinctly in a cavity the size of a walnut 
as in one corresponding in capacity to the whole of the pleural sac. 
Its presence does not absolutely prove that there is communication 
between the cavity and the outer air, although in the great majority of 
cases such a communication does in fact exist; nor does it prove that 
the cavity to which it is due is an abnormal cavity, for it may, when 
detected at the lower part of the left side of the chest, be referable to 
the stomach ; nor, again, does it necessarily throw light on the form of 
the cavity or the structure of its walls, although, for the most part, we 
have reason to suspect when we hear it that the cavity or some part of 
it is of a rounded form, and that the walls are somewhat smooth and 
elastic, or, at all events, of such a character as to allow of reverbera- 
tion. The cause of this amphoric resonance is obviously the rever- 
beration, or succession of echoes, which occurs between the opposite 
sides of the cavity when any impulse or sound capable of originating 
it reaches the air in its interior. The chief conditions under which 
amphoric resonance manifests itself in connection with cavities are the 
following: 1. It attends the respiratory sounds, and more particularly 
that of inspiration. It is important, however, to observe that the 
respiratory sounds yielded from a cavity are, apart from the superadded 
resonance, tubular ; and that if, from any circumstance, the musical 
twang be absent from them, there is nothing left by which they can 
be distinguished from ordinary tubular breathing. It is probably 
never produced in this case unless the cavity communicates with a 
bronchial tube or by a fistulous opening with the external parts ; and 
although it is probably not essential to its production that there shall 
be actual movement of air into and out of the cavity, there is no doubt 
that such movement tends largely to intensify it. 2. It attends both 
the sounds of vocalization and those of coughing. 3. It may be 
evolved over large cavities by percussion of the thoracic walls which 
bound them. 4. It gives a metallic quality to the various rales or 
rattles which are produced in them or in their vicinity by the passage 
of air through fluid. It should be noted, however, that short sharp 
sounds like those of ordinary largish crepitation more readily induce 
an audible echo than do the duller, less intense sounds of respiration 
and the like, and that hence crepitation often becomes metallic in small 
cavities, which give no such quality to respiratory, vocal, or tussive 
sounds, and sometimes even in the normal cavities of the bronchial 
tubes. Lastly, in large cavities we not unfrequently get that per- 
fection of amphoric resonance which is termed metallic tinkling ; a 
sound which is always most characteristically evolved in response to 



364 



DISEASES OF THE RESPIRATORY ORGANS. 



some sharp detonation, such as is produced by the bursting of a largish 
bubble or by the fall of a drop of fluid from above on to a surface of 
fluid below. 

The cavernous echo, although in many cases remarkably distinct 
and unmistakable, is in some cases so feeble that it fails to be trans- 
mitted along the ordinary stethoscope, and can be detected only by aid 
of the binaural stethoscope or by the ear directly applied to the chest. 
Further, it may be, and often is, effectually concealed by the interven- 
tion between the cavity and the thoracic walls of a layer, however 
thin, of crepitant lung-tissue. And, again, it is important to know 
that cavities of considerable size, especially if there be no communica- 
tion, or only imperfect communication between them and the bronchial 
tubes, often yield no sound whatever due to themselves, and merely 
very feebly conduct tubular or even healthy respiratory sounds due to 
the lung-tissue in which they are imbedded. 

There are yet one or two other sounds which may be developed 
within cavities, and may here be included within the meaning of the 
term cavernous respiration. It is possible, for instance, that a cavity 
may be of such a size and shape as to be capable of resonating to some 
particular note, and that the production of that note by the patient in 
his larynx may be then attended with special resonance within the 
cavity. And, again, it sometimes happens that when a cavity com- 
municates, by a flap-like or valvular opening, with a bronchial tube, 
there is no sound audible over the cavity during ordinary respiration 
or during the early period of a forcible inspiration, but that during the 
course of the latter the air rushes into the cavity with an audible click, 
or hiss, or gurgling sound, a phenomenon which is repeated whenever 
the patient inspires deeply. 

c. BronchopJiony, Pectoriloquy, and JEgophony. — The terms pectoril- 
oquy and bronchophony have been employed with great laxity, even 
by those who assume to be authorities upon the subject of auscultation. 
It has been frequently asserted that bronchophony as it becomes more 
marked passes into pectoriloquy, as though the two conditions were 
mere grades of the same phenomenon. This, however, is certainly not 
the fact ; bronchophony never becomes converted into pectoriloquy, 
although they are often associated ; loud bronchophony, indeed, drowns 
the pectoriloquy with which it may be associated ; and, in order to be 
certain of the existence of pectoriloquy, it is always best to annul the 
effects of bronchophony by making the patient speak in a whisper. 
As we have already pointed out, bronchophony is the offspring of 
laryngeal intonation, pectoriloquy of the articulate sounds developed 
within the cavity of the mouth. 

Bronchojihony is almost identical with the sound which may be 
heard through the stethoscope applied over the trachea of any one who 
is effecting laryngeal intonation or speaking aloud. It means preter- 
natural distinctness or loudness, with little alteration of quality of the 
laryngeal musical tones as conveyed to the ear through the tissue of 
the lung. To some extent bronchophony may be regarded as a normal 
phenomenon, especially over those parts of the thoracic walls which 
correspond to the position of the trachea and bronchi ; moreover, its 



AUSCULTATION. 



365 



intensity both in health and disease presents considerable variations. 
Hence in determining the presence or absence of abnormal bron- 
chophony we must not be content to note that the voice-resonance is 
louder in one part than another, but we must observe whether it is 
relatively loudest over those parts of a lung in which it is normally 
comparatively feeble, and especially we must be careful to compare the 
resonance of the voice in corresponding parts of the two sides of the 
chest. Bronchophony is generally developed over consolidated lung- 
tissue, pneumonic, tubercular, or other, and over the sites of vomicae. 
The dependence of bronchophony on the sounds produced by the 
vibrations of the vocal cords is too obvious to need discussion. And 
its development in abnormal situations is clearly due to the same com- 
bination of causes as that to which we have ascribed the phenomena of 
tubular breathing : namely, 1st, the conduction of the musical vibra- 
tions along the patent bronchial tubes or tubes and cavities, into the 
very substance of the consolidated tissue; and, 2d, the ready transmis- 
sion of these vibrations thence through this tissue to the surface of the 
chest. Skoda attributes bronchophony, as he does tubular sounds, to 
consonance of the laryngeal sounds within the bronchial tubes. We 
are far from denying that the tubes may consonate to musical sounds, 
or that they do so consonate in certain cases. But a tube of a certain 
definite length can only consonate to a certain definite note, and pos- 
sibly to some of the higher harmonics of that note ; and assuming 
(what seems scarcely possible) that the length of tube capable of con- 
sonating is to be measured from the rima glottidis to the terminal part 
of a bronchial tube at the base of the lung — a length of about twelve 
inches — the lowest note to which it (being a pipe closed at both ends) 
could consonate would be one produced by undulations a foot long, or 
one lying between B and C of the treble clef. There are good reasons 
for believing that the consonating note would be much higher. Xow 
if this explanation were true, the deeper tones of the voice, which are 
actually loudest in bronchophony, should be comparatively inaudible, 
and of acute tones one only, or one and some of its harmonics, should 
be conveyed to the ear. But this is certainly not the case. 

Pectoriloquy implies the conveyance through the stethoscope placed 
on the chest of the articulate utterances of the person auscultated, as 
though he were applying his lips to the instrument and speaking 
through it into the ear. We have pointed out that this phenomenon is 
always to be heard most distinctly when the patient whispers, because 
then it is uninterfered with by the noise of the laryngeal notes. There 
is another reason why it should then be most audible. Since articulate 
sounds are produced in the mouth, it is obvious that, in order to reach 
the bronchial tubes, they must pass the portals of the larynx. But in 
loud speaking these portals are closed and must hence materially ob- 
struct the transmission of such sounds ; in whispering, on the other 
hand, they are to a greater or less degree patent, and the obstacle to 
their transmission is necessarily proportionately diminished. Pectoril- 
oquy and bronchophony are not necessarily concurrent phenomena. 
Nevertheless, it is certain that pectoriloquy, like the other, is often de- 
tected both over consolidated lung-tissue and over cavities. We believe 



366 



DISEASES OF THE RESPIRATORY ORGANS. 



that it is most frequently and most distinctly audible over cavities 
which freely communicate with bronchial tubes. 

JEgophony is a modification of bronchophony, and gradually passes 
into it. It is generally compared, as its name implies, with the bleat- 
ing of a goat, or with the squeaking voice adopted by the exhibitors of 
" Punch and Judy." These comparisons are by no means inapt. The 
voice transmitted along the stethoscope materially differs in quality from 
the voice as it emanates from the patient's mouth ; it is, even if musical 
and full-toned as uttered, tremulous, bleating, and high-pitched as it 
reaches the auscultatory ear. Some degree of this quality of sound 
may occasionally be recognized, even in health, over the lower portion 
of the chest behind. But it is only heard in perfection in the neighbor- 
hood of the lower angle of the scapula in cases of moderate pleuritic 
effusion ; and indeed, when well marked, may be regarded as pathogno- 
monic of this condition. It is obvious that the peculiar bleating high- 
pitched character is due, as Dr. Stone has pointed out, to imperfect 
transmission of the voice, to the fact that its graver tones are lost or 
greatly enfeebled in transmission, while the higher tones and the har- 
monics of the graver .tones are comparatively unaffected. In support of 
this view may be mentioned the fact that the segophonic sound, though 
apparently clearer, is often distinctly feebler than the normal voice- 
resonance to be heard over the healthy lung. Sound, as is well-known, 
is readily transmitted through either gases, fluids, or solids, but it does 
not so readily pass from one of those media to the others ; and it seems 
obvious therefore that the sounds produced within or carried into the 
bronchial tubes should experience some degree of filtration (so to speak) 
in passing from the tubes to the solid lung-tissue, from this to fluid, 
from this again to the thoracic parietes, and thence through the stetho- 
scope to the ear. High notes are more penetrating than those of graver 
tone, and would hence be less likely to suffer in their passage. 

In association with pectoriloquy, bronchophony, or segophony, there 
can generally be detected a distinct whiff of tubular quality, either ac- 
companying or following the articulate or vocal sounds. In broncho- 
phony and segophony this is perceptible almost exclusively at the end 
of syllables, and chiefly at the end of those terminating with the explo- 
sive consonants b,p, t, d, k, and hard g, and is obviously due to the non- 
vocal rush of air through the open glottis, which as a rule follows on 
the utterance of these sounds. In whispered pectoriloquy a similar 
whiff not only succeeds each syllable, but accompanies it during the 
whole period of its enunciation. These are merely tubular expiratory 
phenomena, due to the same cause as determines the ordinary tubular 
expiratory sound, and have no special significance. It should be added 
that under similar circumstances, a like whiff or blowing sound follows 
each sonorous expiratory shock of cough. 

d. Crepitation Rales. — When mucus, serum, blood, or other fluids 
are contained in the air-tubes, the passage of air through them is at- 
tended with a variety of sounds to which the above and other names 
have been given. These are for the most part due to the passage of 
air in the form of bubbles of various sizes, and to the rupture of these 
bubbles at the surface of the fluid through which they pass, or to the 



AUSCULTATION. 



367 



separation of sticky surfaces. The size of the bubbles has necessarily 
a relation to the size of the tubes or cavities in which they occur. 
Thus if they be formed in the air-cells or bronchial passages they must 
be excessively minute, if in the trachea or larger bronchi they may be 
expected to be and generally are of considerable size. The sounds to 
which they give rise will depend partly upon their size, partly upon 
their number, partly upon the dimensions of the channel or cavity 
within which they are contained, and partly on the presence or ab- 
sence of consolidation in the lung-tissue around. Fine crepitation is 
produced only in the air-cells and bronchial passages, and may be 
regarded as almost characteristic of the first stage of pneumonia. It 
is apparently due to the rupture of innumerable small bubbles, which 
individually are almost inappreciable, but collectively constitute a 
sound which has been aptly likened to that produced by rubbing the 
hair between the finger and thumb. Large crepitation. — In all forms 
of crepitation except that just spoken of, the bubbles which burst at 
one time are comparatively few, moreover they are individually dis- 
tinguishable, and differ to some extent from one another in sound. 
The collective sonorous result therefore is more or less coarse and 
irregular. In some cases two or three crackles or clicks only can be 
detected in the course of an inspiration or of an expiration. In other 
cases they are so numerous that the whole of inspiration and perhaps 
the whole of expiration are noisy with them. It would be impossible 
to describe all the minute varieties of crepitation which may be included 
under the name which we have here selected. It is sufficient to say 
that they are probably all due to the presence of fluid in medium-sized 
and large tubes, and that the differences which are presented depend 
partly on the quantity of fluid present, partly on its quality, and partly 
on the force with which air is driven through it. Gurgling. — This 
term fairly well explains itself, but is at the same time difficult to de- 
fine. Gurgling implies partly large crepitation, such as may be heard 
in the trachea, partly the sounds which result from the mere agitation 
of fluid, falling, splashing, churning, and the like. It occurs in large 
tubes and in cavities. Metallic crepitation. — This term may be applied 
to large crepitation in which the bursting of the bubbles is attended 
with a distinct musical twang or metallic resonance. It is developed 
either in cavities or in large tubes. We have pointed out that cavern- 
ous or metallic respiration is never met with in undilated bronchial 
tubes; the sharp, short sound, however, of a bursting bubble develops 
an audible resonance under conditions which would fail to affect simi- 
larly the prolonged and comparatively feeble respiratory murmur. 

e. Bhonchus. — The word is often used synonymously with rale, and 
both are often applied to all varieties of unnatural sounds caused by 
the presence of fluid in the bronchial tubes, or by diminution of their 
diameter. Bale, however, strictly means rattling or crepitation, which 
is essentially an unmusical sound; whereas rhonchus signifies snoring, 
a sound always to some extent musical, and may conveniently be made 
to embrace all abnormal musical sounds which are occasioned in the 
bronchial tubes. Such sounds have sometimes a very deep tone, and 
almost exactly resemble an ordinary snore; sometimes they may be 



368 



DISEASES OF THE RESPIRATORY ORGANS. 



likened to the cooing of a dove ; sometimes, on the other hand, they 
are exceedingly high-pitched and of a whistling or hissing character. 
The deeper notes are usually termed sonorous, the acuter notes sibilant. 
The former may produce, like the voice itself, distinct fremitus in the 
thoracic parietes, and both may be distinctly audible, not only to the 
patient himself, but to the mere bystander. The cause of rhonchus is 
not the bursting of bubbles or the passage of air through fluid, but the 
passage of air through a tube narrowed at some point either by thick- 
ening of the parietes, or by the adhesion of a plug of tenacious mucus. 
The almost complete closure of the tube, like the corresponding closure 
of the glottis in intonation, compels the passage of the air in a series of 
successive puffs, which soon become rhythmical, and hence a musical 
note results. The pitch of the musical note depends on various com- 
plex conditions, the exact influence of each one of which it would be 
difficult to estimate, but depends in a very considerable degree on the 
size of the bronchial tube within which it is developed. Thus, as a 
general rule, hissing and whistling sounds, or sibilant rhonchi, are de- 
veloped in the smaller tubes, and grave tones or sonorous rhonchi are 
the product of the larger ones. 

/. Splashing. — In large cavities containing air and limpid fluid, espe- 
cially therefore in cases of effusion into the pleura, associated with 
pneumothorax, a distinct splashing sound may often be caused by the 
process termed " succussion," in other words by giving the patient a 
smart shake. This sound is often audible to the patient himself as well 
as to other attentive listeners standing by. It may of course be more 
readily recognized by auscultation. 

g. Amphoric Bubble. — In cases of hydropneumothorax may also be 
very rarely recognized a sound, to which the name amphoric bubble 
may perhaps be given. Our attention was first directed to it by Dr. 
T. A. Barker. On applying the stethoscope to the back in the inter- 
scapular region while the patient was sitting erect, and then making 
him gradually bend his trunk forwards, a sound, exactly like that 
which occurs during the decanting of wine, was distinctly audible. It 
was single only, but could be elicited as frequently as the patient was 
made to bend his body forwards to a certain angle. It was obviously 
due to the facts that the partially collapsed lung hung down from the 
apex of the pleural cavity so as to form an incomplete septum between 
its anterior and posterior parts ; that the lower margin of the lung dip- 
ped into the pleural fluid, thus rendering the air-chamber behind the 
lung and that in front of it discontinuous ; and that consequently with 
change of posture, the level of the fluid tended to rise in one ca vity and 
sink in the other, until the sudden passage of air from the one to the 
other was permitted under the septum. 

h. Friction-sounds are caused by the attrition of opposed surfaces of 
the pleurae. They never occur in the healthy pleura, and it is essential 
to their production that the opposed surfaces be roughened by inflam- 
matory or other deposit. Further, they have very little intensity, and 
are little if at all audible beyond the spot at which they are developed. 
Friction-sounds present many varieties of character. In some cases 
there is a uniform to-and-fro murmur accompanying inspiration and 



AUSCULTATION. 



369 



expiration, and having a close resemblance to the sound produced by 
rubbing two surfaces of paper one upon the other. In some cases the 
sound differs little if at all from some varieties of intra-pulmonary 
crepitation. There may be a continuous crackling attending one or 
both respiratory movements, or merely a few isolated clicks or crepita- 
tions. In a large number of cases the sounds, whether they be fine or 
coarse, occur in a series of irregular jerks. The jerks, indeed, may exist 
without the presence of actual friction-sounds, in which circumstances 
the respirations become (over limited arese) "jerky," or, as they are 
commonly called, "wavy." Friction-sounds have received various 
names, such as grazing, rubbing, creaking, and the like, which to some 
extent express their quality. They have also been described as " super- 
ficial" in character. It need scarcely be remarked, however, that this 
epithet can have no other meaning, as applied to sounds, than that they 
are loud or distinct. Its use is altogether objectionable, as tending to 
cause confusion between the facts which we observe, and the inferences 
we deduce from them. In cases of pleural friction, the rubbing of the 
opposed surfaces may produce a tremor in the thoracic walls, readily 
detectable by the hand. 

Detection of Cavities, Consolidated Lung, and Pleural Effusion. 

Before leaving the subjects of auscultation and percussion, it may 
be convenient to recapitulate the phenomena which attend and indicate 
the presence of cavities, of consolidated lung, and of pleural effusion. 
The detection of cavities is often very important; and in a large num- 
ber of cases, no doubt, by considering the patient's history, the results 
of periodical examinations of his chest, and the presence or absence of 
certain special acoustic phenomena, we may arrive at a fairly correct 
conclusion. But the acoustic phenomena which by their presence 
prove the existence of a cavity are, as Skoda asserts, very few indeed. 
Dulness, bruit de pot fele, normal resonance, tympanitic or modified 
resonance, may each be present. Feebleness with indeterminate char- 
acter of the respiratory sounds, tubular sounds, gurgling, may also 
each be present in its turn. There is probably always more or less 
marked 'bronchophony and pectoriloquy. Pectoriloquy, indeed, is 
probably more distinct, as a rule, over cavities than over merely con- 
solidated lung. The only sounds, however, which positively indicate 
the presence of a cavity, are : 1st, the musical or metallic ring or reso- 
nance which sometimes accompanies the respiratory sounds, the voice, 
the movements of fluid in the cavity, and the percussion-stroke upon 
its walls ; 2d, the splashing sound caused by succussion ; and, 3d, the 
production of the amphoric bubble to which we have adverted. But 
these sounds may all be absent from cavities even of large size. 

[More than twenty years ago, Dr. Austin Flint pointed out certain 
differential characters, consisting principally in variations of pitch and 
quality between tubular and cavernous respiration, attention to which 
will often enable the auscultate r to recognize the presence of a cavity, 
which might otherwise have escaped detection. The principal points 
of distinction are as follows : In bronchial respiration, the expiratory 

24 



370 



DISEASES OF THE RESPIRATORY ORGANS. 



sound is of higher pitch, and usually more intense and prolonged than 
the inspiratory, while both sounds are distinctly tubular in quality. 
In cavernous respiration on the other hand, the expiratory sound is 
much lower in pitch than the inspiratory, both sounds being non- 
vesicular in quality.] 

The conditions which collectively indicate consolidation are sense of 
resistance, impaired or annulled resonance, increase of vocal fremitus, 
tubular breathing, or correspondingly modified conditions of rhonchus 
or crepitation, bronchophony, and pectoriloquy. These conditions are, 
however, by no means necessarily all present in every case. 

The indications of pleural effusion are dulness on percussion, with 
variation of the limits of dulness and resonance in accordance with 
variation of posture, tubular breathing, or absence of respiratory sound, 
impairment or suppression of vocal fremitus, and aegophony. To which 
may be added dilatation of the affected side and of the intercostal spaces, 
with sometimes obvious fluctuation, displacement of the diaphragm 
downwards, and of the mediastinum to the opposite side. But, again, 
many of these phenomena are often absent from otherwise well-marked 
cases of effusion. 

Spirometry. 

It is sometimes useful to ascertain what Dr. Hutchinson calls the 
"vital capacity " of the chest by means of an instrument made on the 
principle of the gasometer, which he terms the "spirometer." He 
measures this capacity by the amount of air which a person who has 
distended his chest to the utmost is able to discharge by voluntary 
expiratory effort. This amount appears to be very constant in rela- 
tion to stature. Thus, the average vital capacity of a man five feet 
seven inches high is about 225 cubic inches, and for each inch of stature 
above this there is an increase, and for each inch below it a decrease of 
about eight cubic inches. It is often difficult to make persons under 
examination exert a sufficient effort to manifest their true vital capacity ; 
but if after having done so there is any wide departure from the scale 
above given there is good reason to suspect the existence of some mor- 
bid condition either involving the lungs or interfering with the due 
performance of the respiratory acts. The vital capacity of women is 
much less than that of men. 



LARYNGITIS. 

Causation. — The chief cause of laryngeal inflammation is exposure 
to cold or wet, or both. It is then sometimes the primary affection, 
but is very often a mere extension of ordinary catarrh or of acute bron- 
chitis. It may be due, however, to many other causes, such as the local 
operation of irritating gases, fluids, or solid particles, among which may 
be enumerated boiling water, vomited matters, and puriform secretions 
furnished by the lung itself ; to the presence of certain morbid condi- 



I 



LARYNGITIS. 



371 



tions or diseases, such as variola, measles, scarlet fever, diphtheria, 
erysipelas, and we may add syphilis and tuberculosis ; to the extension 
of inflammation from subjacent tissues ; and even to sustained or vio- 
lent exertion of the larynx, as occurs in clergymen and other public 
speakers, and in those who strain themselves in coughing or shouting. 
It may be determined also by local violence. There are, further, many 
conditions which predispose to laryngitis ; among the most important 
of which is the fact of having suffered from a previous attack, or the 
presence of Bright's disease. 

Morbid Anatomy. — The local changes which attend and indicate 
laryngitis are those of inflammation of mucous membrane generally, 
modified to some extent by the peculiarities of arrangement and struc- 
ture which the larynx presents. The mucous membrane and the sub- 
jacent tissues are more or less deeply congested and oedematous ; and 
the epithelial surface, at first (as in ordinary nasal catarrh) preter- 
naturally dry, soon begins to secrete, though not in large quantities, a 
somewhat glairy, transparent mucus, which subsequently becomes 
thick and muco-purulent. In ordinary mild cases the tumefaction and 
reddening are slight yet pretty uniformly diffused, the vocal cords also 
being probably more or less injected and swollen, and perhaps studded 
with flakes of adherent mucus. In more severe cases the submucous 
tissue may be largely infiltrated and oedematous, and hence the affected 
regions very often assume a translucent, almost jelly-like, aspect, 
though still presenting a congested surface. Such swelling, or oedema, 
may mainly affect the epiglottis, or the aryteno-epiglottidean folds, or 
the false vocal cords, or some other limited tract, or may be general. 
It must be borne in mind, however, that those parts the tissues of 
which are closest in texture suffer least in this respect, and that hence 
the free edge of the epiglottis and the true cords are, for the most part, 
but little affected. In most cases the secretion from the mucous mem- 
brane simply presents the ordinary characters of mucus or of muco- 
pus. But in some (even in the absence of diphtheria) an adherent 
false membrane forms upon the surface. This sometimes follows the 
attempt to swallow boiling water. Ulceration is an unusual sequel of 
ordinary inflammation. Still it does occur; and most commonly, per- 
haps, in the course of phthisis and of constitutional syphilis, even when 
no specific lesions are present. 

Ulceration in phthisis is generally the result of excoriation. It 
commences in the form of shallow, round, or oval saucer-like depres- 
sions, of an ashy color and with congested margins. The most im- 
portant, if not the most common, seat of such ulcers is the point of the 
'processus vocalis. An ulcer in this situation tends to extend deeply, 
to expose more or less of the arytenoid cartilage, and to lead to its 
partial or even total destruction by caries or necrosis. There is a 
great tendency indeed, both in the course of phthisis and of syphilis, 
for the ulceration to involve the cartilages — the arytenoid, cricoid, and 
thyroid — and to cause their erosion or necrosial destruction. In some 
cases the cartilaginous disease takes its origin in inflammation of the 
perichondrium. For the most part the affected cartilages have under- 
gone more or less complete ossification. The forms of laryngitis last 



372 



DISEASES OF THE RESPIRATORY ORGANS. 



referred to may be regarded as essentially of a chronic nature ; but 
simple laryngitis also may become chronic. The anatomical charac- 
ters of this variety differ little from those of the acute affection. The 
chief distinctions are that, in the former case, the inflammatory redness 
is less intense, and the thickened tissues become more opaque and ap- 
parently more solid. They lose their peculiar (Edematous character. 
It may be added that when laryngitis becomes chronic the follicles of 
the affected surface tend to undergo manifest hypertrophy, and that 
hence to some such cases the name of glandular laryngitis has been 
given. 

Symptoms and Progress. — 1. Acute laryngitis is mainly dangerous 
from the fact that it is liable to cause obstruction to the passage of air 
through the rima glottidis, and hence death from suffocation. The in- 
flammation in itself is for the most part of little intensity, and gives 
rise to comparatively slight constitutional disturbance. There may be, 
and indeed usually is, during the earlier period of the affection, more 
or less elevation of temperature, acceleration and hardness of pulse, 
flushing of the face, furring of the tongue, thirst, and loss of appetite. 
But in favorable cases these symptoms soon subside, and in unfavora- 
ble cases become replaced by those of asphyxia. 

The special symptoms of laryngitis are often preceded by those of 
ordinary catarrh and especially by those of catarrhal affection of the 
fauces, which, in many respects, they resemble. The patient complains 
of dryness or roughness, soreness, itching, pricking, or aching, or it 
may be of several or all of these sensations, which he refers to the back of 
the throat and to the region of the thyroid cartilage. There is generally 
also some tenderness to touch, and there may be absolute pain when 
the parts are roughly handled. The sense of soreness is, for the most 
part, aggravated by the act of swallowing, especially if solid matters 
be taken, and there is commonly also a good deal of aching thus caused 
in addition to the soreness. The dryness and irritability of the throat 
compel the patient nevertheless to make constant efforts at deglutition, 
and at clearing the throat, and excite more or less frequent, spasmodic 
attacks of cough. The voice becomes altered in quality, and respira- 
tion somewhat impeded. The examination of the throat with the I 
laryngoscope reveals congestion, with more or less thickening, of the 
mucous membrane, and if the parts above the vocal cords be much 
affected they may entirely conceal the rima glottidis and its surround- 
ings from view. 

Certain of the symptoms here enumerated require to be considered a 
little more in detail. Some degree of interference with the freedom of 
respiration is probably always experienced, and this, under the influ- 
ence of excitement or of sudden spasm, may readily amount to mani- 
fest dyspnoea ; expiration is a little prolonged, and tends to be perhaps 
a little wheezy. But very often the interference with respiration is 
much more serious ; both inspiration and expiration (the former more 
especially) become harsh or whistling, noisy and prolonged, and the 
patient suffers from continuous difficulty of breathing. In still more 
serious cases all the symptoms of asphyxia become developed. The 
patient sists up in bed gasping for breath, which is still harsh, wheezy, 



LARYNGITIS. 



373 



or whistling; with his head thrown back, his mouth open, his nostrils 
dilated, his respiratory muscles acting with spasmodic force; anxious, 
restless, throwing his arms about, or clutching at any support which 
may be near; with eyes prominent and staring, face livid and ghastly, 
skin bathed in perspiration, and pulse rapid, small, failing, and perhaps 
irregular. Under these circumstances death may be caused by sudden 
complete obstruction of the rima glottidis. More commonly, however, 
the patient begins to ramble in his mind, and presently passes into a 
condition of insensibility, upon which death gradually supervenes. 

The voice is almost always somewhat altered in quality ; it becomes 
hoarse, or uncertain, or reduced to a mere whisper. In the beginning 
it is in general merely hoarse. It is somewhat rougher than natural, 
and at the same time deeper toned — phenomena which depend either 
on the adhesion of mucus to the edges of the vocal cords, or on some 
modification in their thickness, elasticity, or tension. This hoarseness 
is sometimes apparent only on rising in the morning, and disappears 
during the day ; it is apt, however, to be brought on again, and to be 
converted into actual aphonia by unwonted use of the voice. At a 
later period of the disease, when the tissues above the vocal cords are 
highly (Edematous, or the cords themselves are much thickened and 
scarcely movable, complete aphonia is usually present. 

The cough varies in severity; sometimes it is incessant, or comes 
on in uncontrollable paroxysms. But it is generally attended with so 
much pain in the larynx that the patient endeavors (probably in vain) 
to suppress it. It is always at first, like the voice, hoarse and loud; 
and in many cases, especially in children, and where there is manifest 
dyspnoea, the inspiratory element of the cough is long, loud, and 
whistling, and the expiratory effort is attended with a remarkably 
harsh, sonorous, metallic clang. Later on, the cough, like the voice, 
becomes ineffective, wheezy, or aphonic. 

Acute laryngitis is very apt to be attended or followed by bronchitis, 
or (especially in children) by collapse and lobular pneumonia — com- 
plications which aggravate the patient's symptoms and add very ma- 
terially to his danger. It is sometimes as rapidly fatal as almost any 
disease with which we are acquainted ; but in a large proportion of 
cases is so mild in its symptoms that but little attention is paid to it; 
it is always, however, attended with risk, and should be carefully 
treated. 

The frequency of the occurrence of laryngitis in a mild form is 
evidenced by the frequency with which persons, after exposure to cold, 
suffer from soreness referable to the larynx, and hoarseness or loss of 
voice. This affection generally lasts for three or four days, subsides 
with increase of laryngeal secretion, and leaves no ill consequences be- 
hind. Dr. Cheyne asserts that hoarseness is an uncommon phenome- 
non in the catarrhal affections of young children, and that its occur- 
rence should make us dread the supervention of croup. Our own 
belief, on the other hand, is that hoarseness is not uncommon in chil- 
dren, and that it has no more serious import in them than in adults. 
The phenomena, however, of slight laryngitis in children under two 
or three years of age, and sometimes even in those who are a little 



374 



DISEASES OF THE RESPIRATORY ORGANS. 



older, are so remarkable that they are often confounded with those of 
spasmodic croup or laryngismus stridulus. The child, after having 
suffered from slight catarrhal symptoms, or sometimes in the midst of 
apparently good health, wakes suddenly during the night in an agony 
of dyspnoea. He starts up in bed with a look of extreme anxiety and 
terror, gasps for breath, inspires laboriously with a hissing or whis- 
tling sound, and coughs at intervals with a series of harsh, loud, me- 
tallic, expiratory shocks ; his voice is hoarse or reduced to a mere 
whisper. After the symptoms have lasted for half an hour or more, 
during which time the patient has been enduring all the horrors of im- 
pending suffocation, they subside, the skin becomes moist, and he falls 
into a comfortable sleep. The next day he probably appears to be 
pretty well, although there may still be some hoarseness of voice and 
the cough may still have a croupy character. It is not uncommon for 
such attacks of dyspnoea to occur during two or three nights or more 
in succession. There can be no doubt that in these cases the attacks 
are mainly spasmodic ; and there is some reason to suspect that they 
are often immediately induced by the entrance of saliva, or even of 
regurgitated food, during sleep, into the larynx. They are very rarely 
indeed fatal. Neither of the above forms of laryngitis, however, differs 
essentially from the rarer cases in which the symptoms early assume 
an aggravated character, and in which the patients die, suffocated, at 
periods varying from a few hours to two, three, or four days. 

2. Chronic Laryngitis. — Under the head of chronic laryngitis may 
be included: first, simple laryngitis, which has assumed a chronic 
form ; second, aphonia clericorum ; and third, ulcerative processes, 
connected especially with pulmonary tuberculosis and with syphilis. 
Acute laryngitis not unfrequently becomes chronic when the patient 
continues to expose himself to the conditions which first caused it. 
The symptoms differ but little from those of the acute affection, ex- 
cepting in their comparative mildness. They are liable, however, to 
exacerbations, and rapid oedema of the submucous tissue may at any 
time ensue. Dr. Mackenzie states that in this form of chronic laryn- 
gitis the aryteno-epiglottidean folds are comparatively rarely congested 
and swollen, but that it is chiefly the false vocal cords, the capitula 
Santorini, and the epiglottis which suffer. 

Aphonia clericorum may originate in catarrh, like other forms of 
laryngitis, or may be the result of simple overexertion. It soon, 
however, and mainly in consequence of the persistent use of the voice, 
becomes a chronic affection. The symptoms are like those of ordinary 
chronic laryngitis, but on the whole are more mild. The patient, 
indeed, often suffers from little except a sense of dryness in the throat, 
persistent hoarseness, and a tendency to hawk and clear the throat. 
Laryngoscopically, the appearances are those of chronic laryngitis. It 
is stated, however, that in this case there is a special tendency to hyper- 
trophy of the laryngeal glands, and that their enlarged orifices may 
often be distinctly recognized. 

It is very uncertain to what extent the laryngeal affection which so 
commonly attends pulmonary phthisis is due to tuberculosis of the 
laryngeal mucous membrane. It creeps on insidiously, and is some- 



LARYNGITIS. 



375 



times fai advanced before the pulmonary disease has made very mani- 
fest progress. It differs from the varieties of chronic laryngitis above 
considered in its progressive aggravation, and in its incurability. At 
the beginning it presents no special symptoms, but as the disease goes 
on the patient suffers from complete aphonia, from dyspnoea, which may 
become exceedingly severe, and from pain and difficulty in swallowing; 
indeed, in many cases swallowing becomes almost impossible, on account 
of the passage of food through the rima glottidis when the act is at- 
tempted. These peculiarities are explicable by the facts that the thick- 
ening of the tissues of the larynx is persistent, and that there is pro- 
gressive ulceration, leading to more or less extensive destruction of soft 
parts, and to caries of the arytenoid and sometimes of the other car- 
tilages. On laryngoscopic examination, the soft parts are seen to be 
more or less thickened, sometimes congested, sometimes pale, and for 
the most part opaque ; and Dr. Mackenzie draws attention to the fact 
that the aryteno-epiglottidean folds usually look like " two large, solid, 
pale, pyriform tumors, the large ends being against each other in the 
middle line, and the small ones directed upwards and outwards." The 
presence of ulcers may sometimes be recognized. Syphilitic affections 
of the larynx are not wholly specific. But, whether specific or not, the 
symptoms to which they give rise are those of progressive chronic laryn- 
gitis. In the later stages of constitutional syphilis, extensive ulceration 
of the larynx is not uncommon, and in this case, as well as in so-called 
" laryngeal phthisis," there is a great tendency for caries or necrosis of 
the various cartilages to take place. Here, however, the epiglottis is 
most prone to suffer. Such complications, no matter what their cause, 
always largely diminish the ultimate prospect of even partial recovery, 
and bring in their train special symptoms in addition to those of simple 
laryngitis. Among these may be mentioned infiltration and oedema of 
the tissues of the neck superficial to the laryngeal cartilages ; fetid 
breath and fetid purulent discharge; the occasional separation of por- 
tions of cartilage or bone, which may either be expectorated or cause 
sudden death by obstructing the laryngeal orifice ; the formation of 
abscesses or sinuses which may open in various positions ; the perfora- 
tion of arteries, with profuse and fatal haemorrhage ; and occasionally, 
as a sequela of the separation of sequestra and of cicatrization, per- 
manent and serious contraction of the glottis or other parts of the 
laryngeal canal. 

Treatment. — The treatment of laryngitis may be divided into the 
constitutional or general, and the local, of which the latter is by far 
the more important The local treatment to the exterior of the larynx 
comprises leeches (which should be applied over the upper part of the 
sternum), blisters and other counter-irritants (which are also best ap- 
plied in the same region), and poultices or hot fomentation^ over the 
larynx itself. For internal local treatment may be employed the inha- 
lation of steam, simple or medicated with volatile aromatic or sedative 
substances, such as turpentine, camphor, benzoin, creosote, or conium ; 
the inhalation of atomized fluids, such as solutions of sulphate of zinc 
or copper, acetate of lead, alum, nitrate of silver, perchloride of iron, 
or tannin ; the application, by means of a sponge or brush, of strong 



376 



DISEASES OF THE RESPIRATORY ORGANS. 



solutions of nitrate of silver (5j ad tincture of perchloride of iron 
(5j> 5ij ad oj), or of the other articles just enumerated ; the insuffla- 
tion of finely-powdered astringents or sedatives ; and scarification of 
the congested or oedematous tissues. In order that the internal local 
treatment may be effectual, it is important that (excepting in the case 
of simple inhalation) the remedies should be applied by means of 
special apparatus under the guidance of the laryngoscope. As to 
general treatment, we must be mainly governed by the constitutional 
condition of the patient and by the character of his attack. In acute 
cases, ipecacuanha, tartar emetic, and other nauseating remedies have 
been largely advocated ; opium, as in most inflammatory affections, 
especially such as are attended with pain or distress, is often of ex- 
treme value. Warm baths, and the retention of the patient in an 
equable, warm, moist atmosphere, are generally of use in the treatment 
of acute cases; in the treatment of chronic cases, iron and other tonics, 
cod-liver oil, change of air, and, if need be, iodide of potassium or 
mercurial salts. 

In the laryngitis which so often attends an ordinary catarrh, it is 
advisable to keep the patient in a warm atmosphere, at any rate free 
from exposure to draughts, to apply hot fomentations or mustard 
plasters externally, to order him to gargle his throat frequently with 
warm milk or with slightly astringent solutions, or to relieve his 
faucial discomfort by the use of gelatinous or oleaginous substances — 
among which may be included common calves'-foot jelly or black cur- 
rant jelly — or to inhale steam. Diaphoresis may be encouraged, and 
expectorant medicines may be administered. Opium is of great value 
in relieving the patient's discomfort. When the case is severe from 
the beginning, or when it begins to assume a serious aspect, our local 
treatment must be more active : leeching externally, and scarification 
within, become then of essential importance. Sometimes in such cases 
swabbing the throat with strong solution of nitrate of silver, perchlor- 
ide of iron, or alum, is followed by the best results. In the stridulous 
laryngitis of young children, the danger is mainly momentary (so to 
speak), and due to spasm; and treatment, therefore, if it is to be effi- 
cacious, must be prompt. Generally it is advisable to place the pa- 
tient in a hot bath, and to apply a sponge wrung out in hot water over 
the larynx. It is usually customary to administer an emetic dose of 
ipecacuanha or sulphate of zinc. It may, however, be questioned 
whether the inhalation of chloroform is not more likely to be benefi- 
cial than the use of an emetic. In the chronic form oi laryngitis, 
local bleeding and scarification are rarely necessary except to relieve 
exacerbations ; but blisters and other counter-irritants externally, and 
the systematic employment of medicated applications to the interior of 
the larynx, are then specially indicated. In the so-called " aphonia 
clericorum," prolonged rest from the use of the voice should especially 
be enjoined. In all cases, whether they be acute or chronic, specific or 
non-specific, it must be borne in mind that we may be called upon at 
any moment to save life by the performance of tracheotomy. The 
need for its performance must generally be determined at the moment. 
It is difficult to lay down precise rules for the guidance of the judgment 



TRACHEITIS. 



377 



of the medical attendant in such cases. It is probably sufficient to say 
that no one ought to be permitted to die of uncomplicated laryngeal 
obstruction without having that chance of recovery given him which 
tracheotomy affords ; that it is unwise to delay the operation until the 
patient is moribund ; that it is better to perform it too early or even 
needlessly than too late ; and, lastly, that it should not necessarily be 
discarded even if the patient appears to be just dead. 



TRACHEITIS. 

Causation. — Inflammation of the trachea arises from the same causes 
as laryngitis and bronchitis, and is generally associated with one or 
other of these affections. More rarely it originates independently, 
being due either to the extension of inflammation from without, or to 
the morbid processes which attend the involvement of its parietes in 
the progress of some morbid growth. 

Morbid Anatomy. — The changes which take place in tracheitis are 
essentially identical with those which characterize laryngitis. The sur- 
face, which is at first drier than natural, soon secretes an overabundance 
of modified mucus, and occasionally, like that of the larynx, becomes 
covered with an adherent false membrane. The mucous membrane 
itself, and the subjacent tissues, become to a variable extent congested 
and infiltrated, and not un frequently, especially in syphilis and in 
phthisis, ulceration takes place. The ulcers are mostly, in the first 
instance, mere excoriations, which tend gradually to increase in area, 
and thus to coalesce, and in depth, so as gradually to expose the car- 
tilages. These latter may thus become eroded or necrosed, and even 
detached and expectorated. Abscesses may form in the walls of the 
trachea, or external to them, and communications may be established 
between its tube and that of the oesophagus. The healing of ulcers 
may produce serious cicatricial contraction. 

The symptoms due to tracheitis are scarcely distinguishable from 
those of inflammation of the larynx. It may be observed, however, 
that there is not necessarily here any pain in the pharyngeal stage of 
deglutition, or any affection of the musical quality of the voice, and 
that, while the danger of suffocation is less, the benefit to be expected 
from tracheotomy is also less. Further, some tenderness in the course 
of the trachea may be expected, some pain in the same situation on 
coughing, and some tenderness or soreness in the passage of food along 
the oesophagus. 

The treatment of tracheitis is, with obvious exceptions as to details, 
identical with that recommended for laryngitis. 



378 



DISEASES OF THE RESPIRATORY ORGANS. 



BRONCHITIS. 

Causation. — Inflammation of the bronchial tubes is chiefly depen- 
dent on exposure to cold, but it arises also, like laryngitis, from the 
inhalation of irritant matters, as a complication or sequela of various 
febrile disorders, such as influenza, hooping-cough, measles, and typhoid 
fever, and in connection with various idiopathic affections, more espe- 
cially heart and kidney diseases. It may be developed also under the 
influence of pulmonary tuberculosis and carcinoma, and probably also 
in connection with syphilis and gout. Its prevalence largely depends 
upon temperature and season, and hence it is chiefly fatal in autumn 
and in winter; it is favored by such occupations as expose persons to 
the influence of irritant or other noxious matters, and such as necessitate 
frequent and sudden exposure to variations of temperature ; it affects 
persons of all ages and of either sex, but it has a marked preference 
for such as have had previous attacks, and is especially fatal in early 
infancy and in old age. 

Morbid Anatomy. — Inflammation of the bronchial tubes, like inflam- 
mation affecting other mucous membranes, is attended with changes in 
their epithelial covering, and in the secretions of the glands, and with 
changes in the subjacent tissues. 

The discharge is, in the first instance, diminished in quantity, but 
soon becomes more abundant than in health, thin, transparent, and 
either watery or viscid, and subsequently acquires more or less opacity 
and thickness, and at the same time a yellowish or greenish tint. 
Sometimes it remains watery, sometimes assumes the characters of pure 
pus, and not unfrequently, if the inflammation be intense, or the con- 
gestion great, presents streaks and spots of blood. Under the micro- 
scope, the viscid, transparent secretion will be found to contain abun- 
dance of shed ciliated epithelial and other cells, and the acquisition of 
opacity is connected with the fact of the more or less complete replace- 
ment of these by cells assuming a more and more embryonic character, 
by fatty or granule-cells, and by pus-corpuscles. In some rare cases 
groups of bronchial tubes are found occupied by laminated fibrinous 
casts, which, on separation, present a branching or tree-like aspect. 

The mucous membrane, in bronchitis, becomes more or less con- 
gested, sometimes intensely congested, and even the seat of minute 
extravasations of blood ; at the same time it undergoes more or less 
infiltration and thickening, and may even assume a granular or villous 
aspect, and become soft or pulpy in consistence. It is important, how- 
ever, to know that, in a large number of cases, especially chronic cases, 
the congestion disappears wholly after death, and the mucous membrane 
seems scarcely changed either in thickness or in texture. 

The inflammatory process may be limited to the surface of the mu- 
cous membrane, but often it pervades the submucous tissue, and in some 
cases involves the whole thickness of the walls of the bronchial tubes, 
leading also to more or less obvious infiltration and induration of the 
connective tissue which surrounds them. In the last case the muscular 
fibres may either, if merely irritated, be stimulated to unwonted action, 



BRONCHITIS. 



379 



or may undergo atrophy or degeneration, and lose their contractile 
properties. In most cases of bronchitis the mucous membrane remains 
whole; but occasionally ulceration takes place. This is more common 
in phthisis than in the uncomplicated disease, and usually commences, 
as does tracheal or laryngeal ulceration, in simple excoriation. The 
excoriations, at first small and round or oval, gradually enlarge and 
coalesce, and at the same time tend to increase in depth. Thus the 
walls may undergo gradual removal (the cartilages disappearing either 
by caries or necrosis), the surrounding lung-tissue may be involved to 
a greater or less extent in the destructive processes, and the tubes con- 
verted into irregular channels bounded by diseased lung-tissue. In 
some cases the destructive process assumes a gangrenous character. We 
may add that ulcerative destruction of the tube-walls occasionally takes 
place from without, as when a pulmonary or glandular or other abscess 
opens into an adjoining tube. It is thus that abscesses about the roots 
of the lungs discharge themselves into the larger bronchi, and that cal- 
careous matter from degenerated bronchial glands also finds its way 
into the bronchial tubes. 

Bronchitis is limited, in a large proportion of cases, to the tubes of 
large and medium size ; but sometimes it mainly or entirely affects the 
minuter tubes. In the latter case, not only is the affection marked by 
greater intensity of symptoms and aggravated danger to life, but the 
local pathological changes assume a more serious character; the thick- 
ening of the mucous membrane tends more perfectly to close the affected 
tubes, and the secretions which are effused into their channels tend to 
accumulate in them, and completely to block them up. And hence 
post-mortem we not unfrequently find the smaller tubes distended with 
pus or mucus, void of air, and quite impermeable. 

The indirect influence of bronchitis over the structural condition 
of the bronchial tubes and of the proper tissues of the lungs is very 
remarkable. As regards the tubes, we have already pointed out that, 
by the extension of ulceration, they may be converted into irregular 
channels. This change, it need scarcely be said, may be seen in its 
greatest perfection in connection with the capillary or terminal tubules. 
But again, independently of ulceration, the tubes, and especially the 
smaller ones, may undergo very considerable dilatation from the com- 
bined effects of simple accumulation of their contents and of inflam- 
matory weakening of their walls. In acute bronchitis, attended with 
much secretion, the lung-tissue often becomes preternatural ly distended 
with air, and retains the accumulated air even after death. This con- 
dition is sometimes incorrectly termed emphysema ; but it not unfre- 
quently proceeds to actual emphysema, in which the vesicular structure 
is more or less seriously disorganized. Besides overdistension, the 
exactly opposite condition of pulmonary collapse is often met with, 
sometimes alone, sometimes associated with overdistension of other 
parts. Collapse is intimately related to another frequent complication 
of bronchitis, and indeed passes by insensible gradations into it; we 
mean lobular pneumonia. All the secondary phenomena arising in 
the progress of bronchitis, which have here been enumerated, namely, 
dilatation and destruction of tubes, dilatation and destruction of air- 



380 



DISEASES OF THE RESPIRATORY ORGANS. 



cells, or emphysema, lobular collapse and lobular pneumonia, form a 
more or less important part of chronic bronchitis, and tend both to 
aggravate its symptoms and to perpetuate them. It will, nevertheless, 
be more convenient to defer their complete discussion. 

Symptoms and Progress. — The symptoms of bronchitis comprise, in 
varying proportions, those of inflammatory fever, those of defective 
aeration of blood, and those directly referable to the condition of the 
bronchial tubes and lungs, to which may be added those arising from 
mechanical impediment to the transmission of blood through these 
organs. 

The symptoms of inflammatory fever are always most pronounced 
at the commencement of acute attacks and of exacerbations of the 
chronic affection, and often wholly disappear, to be replaced by other 
conditions, during the progress of the disease. The temperature, ex- 
cepting in very severe cases, especially of capillary bronchitis, and in 
young children, rarely exceeds 100° or 101°. In exceptional cases it 
may amount to 102°, 103°, or 104°. With elevation of temperature 
there may at first be chills or rigors, and more or less dryness of skin. 
But perspirations, which may be profuse, are very apt to alternate with 
dryness or to replace it. The pulse becomes accelerated, the respira- 
tions somewhat hurried, the tongue furred; the patient has thirst, loss 
of appetite, constipation, and scanty turbid urine; and he probably 
complains of more or less headache, and of febrile pains about his 
limbs; he is apt to be very drowsy, though often wakeful at night. 

Diminished aeration of the blood tends to the reduction of tempera- 
ture, to interference with the processes of nutrition, and to enfeeble- 
ment of the heart's action and of the pulse. The temperature of bron- 
chitis may hence be subnormal even in acute attacks. The pulse, 
moreover, is sometimes full and incompressible, owing either to increase 
of arterial tension secondary to venous obstruction, or to poisoning of 
the nervous centres; and in chronic cases it is often abnormally slow. 
The face, and especially the lips and cheeks, assume a pale or more or 
less livid hue ; profuse perspirations break out, and there is a tendency 
to impairment of the mental faculties, to delirium, and coma. 

The local symptoms are due to the processes going on in the bron- 
chial tubes. They comprise cough, at first dry and irritable, later on 
freer and attended with expectoration; difficulty of breathing, with in- 
crease in the number of respirations and in the efforts required of the 
patient ; comparative prolongation of the acts of expiration ; and the 
various forms of rhonchus and crepitation which are caused by thicken- 
ing of the bronchial mucous membrane, or by secretion into the tubes. 

1. Acute Bronchitis. — The symptoms of an attack of bronchitis vary 
considerably according to its severity and to the conditions which cause 
or which complicate it. In its mildest form it is a comparatively trivial 
affection. It usually then commences with ordinary catarrhal inflam- 
mation of the upper part of the respiratory tract, which gradually 
travels downwards, involving first the larynx, then the bronchial tubes. 
It is attended with slight febrile disturbance, irritability of the bron- 
chial mucous membrane, tickling or uneasy sensations in the throat, 
burning, soreness or rawness within the chest, and more or less frequent 



BRONCHITIS. 



381 



cough, the paroxysms of which are attended with considerable aggra- 
vation of the intrathoracic discomfort. There are frequently, also, 
some tenderness over the manubrium, and more or less tenderness and 
aching of the muscles of the upper part of the front of the chest. The 
cough is at first dry, but in a short time becomes loose and attended 
with the discharge of transparent glairy mucus. With the progress of 
the case the sputa become opaque and mucopurulent, then gradually 
cease, and health is restored at the end of a few days, or it may be after 
the lapse of a week or two. 

In more severe cases, the symptoms are the same in kind, but all 
much aggravated. The febrile phenomena which usher in the attack 
are more intense, the cough and pain in the chest are more distressing, 
and are attended with more or less obvious dyspnoea. There may be 
indeed while the mucous membrane is simply swollen, and the cough 
is yet dry, great apnoeal distress and lividity of surface, and the patient 
may even at this stage die asphyxiated. More commonly, however, 
as in the former case, the mucous surface ere long begins to dis- 
charge, and the cough to be attended with expectoration, which, except 
that it is probably much more profuse and apt to be streaked with 
blood, passes through the ordinary phases. During this period, also, 
death may take place from accumulation of fluid in the bronchial tubes 
and consequent slow asphyxia ; or, without the actual supervention of 
asphyxia, the patient may gradually pass into a typhoid state, with 
feeble, quick, irregular pulse, dry cough, copious perspirations, and de- 
lirium; or he may sink from a combination of these conditions. Occa- 
sionally death is sudden, owing to the sudden obstruction of some of 
the larger tubes. 

The most dangerous form of acute bronchitis is that which com- 
monly passes by the name of " capillary bronchitis." It is that form 
in which the inflammation mainly, if not exclusively, affects the mi- 
nuter bronchial tubes. It is most common in children, yet not unfre- 
quent in persons of more advanced age. The fever which ushers it in 
is generally pretty intense, the difficulty of breathing and lividity con- 
siderable; the cough, however, may be much less troublesome than in 
other cases, and even during the stage of secretion may, owing to the 
difficulty of dislodging accumulations in the minuter tubes, remain in- 
efficacious and dry. Further, there is generally comparatively little 
intrathoracic pain, even in violent coughing. The tendency in capillary 
bronchitis is towards speedy death from asphyxia and debility. 

The auscultatory phenomena of bronchitis comprise mainly sono- 
rous and sibilant rhonchi, and crepitation of various sizes. Musical 
rhonchi are chiefly heard during the dry stage, crepitation during the 
later stages, but even then musical sounds are apt to be present to a 
greater or less extent. In capillary bronchitis the rhonchus is mostly 
sibilant, and the crepitation small. The sounds elicited by percussion 
differ little from those of health. If the lung-tissue be much distended 
with air, as it often is, the percussion-sound may be somewhat more 
resonant than normal ; but obvious dulness is rarely produced, even if 
there be lobular collapse, unless the collapse be extensive, or unless 
pneumonia or other complications be present. 



382 



DISEASES OF THE RESPIRATORY ORGANS. 



2. Chronic Bronchitis. — Bronchitis often assumes a chronic form, 
especially among the laboring classes, and in persons of middle or ad- 
vanced age. It may, however, become chronic at any age, or in persons 
of any grade of society. When a patient who is suffering from an 
attack of bronchitis continues to expose himself to the conditions which 
caused it, the inflammation is likely to be kept up ; and, again, bron- 
chitis is one of those affections which, when once they have been expe- 
rienced and cured, tend to recur on the slightest provocation. The 
ordinary history of a case of chronic bronchitis is to the effect that the 
patient, after exposure to weather, probably during the winter, has an 
attack of the disease, from which he recovers during the ensuing spring, 
remaining fairly well until the approach of the following winter ; that 
then a fresh attack is contracted, from which again recovery takes 
place ; that these attacks of winter cough then recur annually, increas- 
ing gradually in severity and duration, and being separated from- one 
another by shorter and shorter intervals of comparative health ; and 
that each such successive interval becomes a period of increasing short- 
ness of breath, until it merges in that of the bronchitic condition, which 
thus becomes continuous, although still probably presenting winter 
exacerbations. Each bronchitic attack differs but little in its symptoms 
from an ordinary acute attack, excepting perhaps that it is rarely at- 
tended with such manifest febrile disturbance, and that the expectora- 
tion is apt speedily to assume the mucopurulent condition and to con- 
tinue of this character, and at the same time to become more or less 
abundant, until the approach of the long-delayed convalescence. 

The successive long-continued attacks generally lead gradually but 
surely to the development of those structural pulmonary changes 
which have been already enumerated, and to those various remote 
lesions referable to long-continued congestion of the systemic venous 
system which equally follow on this disease and on cardiac affections. 
The mucous membrane tends to secrete more abundantly than natural, 
even when the patient is otherwise apparently well ; emphysema, or 
dilatation of the tubes, or both of these conditions, gradually super- 
vene ; the right side of the heart becomes dilated and hypertrophied, 
systemic venous congestion ensues, and subsequently anasarca, and 
hepatic and renal complications. The symptoms due to these lesions 
are consequently added one after another to those of simple bronchitis ; 
the patient soon begins to suffer from persistent shortness of breath and 
bronchial accumulation, and sooner or later becomes cyanotic or drop- 
sical, and suffers, it may be, from jaundice or albuminuria. 

It should be added that the thorax of a patient who has suffered 
long from chronic bronchitis gradually assumes, in consequence partly 
of his persistent powerful inspiratory efforts, partly of emphysema, a 
rounded form — the well-known barrel-like shape which is so common 
in this affection. 

Cases of chronic bronchitis, within certain limits, differ widely from 
one another in their severity and in the symptoms with which they are 
attended. We may perhaps mention that in some the bronchial secre- 
tion is so little in quantity, other symptoms being well developed, that 
the affection has been termed dry bronchitis; that, in some the dis- 



BRONCHITIS. 



383 



charge is extraordinary profuse, and that with them the affection has 
hence had the name of bronchorrhoea given to it; and that, in other 
cases, even where no gangrenous condition is present, the expectoration 
is disgustingly fetid — a condition which is said to be chiefly met with 
when there is dilatation of the bronchial tubes. The expectoration 
and the auscultatory, percussive, and tactile phenomena yielded by 
patients suffering from chronic bronchitis present no material differ- 
ences from those presented by patients suffering from the acute dis- 
order, and call, therefore, for no special description. Death, in which, 
sooner or later, the chronic disease so often terminates, is usually due 
either to asphyxia, or asthenia, or to a combination of these conditions. 

The expectoration of laminated casts of the bronchial tubes is an 
event which may naturally be looked for in cases of diphtheria in which 
the diphtheritic process has travelled from the larynx into the trachea 
and thence downwards. And, indeed, since the diphtheritic pellicle 
may form upon any part of any mucous membrane, there is little 
doubt that it occasionally forms in the smaller bronchial tubes inde- 
pendently of any such affection of the larynx, trachea, or bronchi, and 
that equally, under these circumstances, expectoration of casts may 
take place. But cases are occasionally observed in which patients, 
whom there is no reason to suspect of diphtheria, spit up such casts 
from time to time. The causes, the pathology, and the symptoms of 
this affection, which has been termed plastic bronchitis, are alike ob- 
scure. All that is positively known is that persons, after a longer or 
shorter period of ill-health, and symptoms sometimes like those of 
slight chronic bronchitis or lobular pneumonia, either without warning 
or after prolonged dyspnoea, expectorate, as the result of a more or less 
suffocative paroxysm of cough, a larger or smaller quantity of this 
material, often in connection with haemoptysis, which may be profuse, 
or with mucopurulent discharge ; that this plastic expectoration may 
then cease or may continue off and on for weeks, months, or even 
years ; and that, although some of such patients die of phthisis, and 
some of the accidents which attend the process of expectoration, the 
majority appear to make a good and permanent recovery. There is 
good reason to believe that the portions of lung-tissue to which the 
obstructed tubes lead are in a state of more or less complete collapse or 
lobular pneumonia ; and indeed, although in most cases there appears 
to have been perfect pulmonary resonance with more or less rhonchus 
and crepitation, a few have been recorded in which, as might be ex- 
pected, there was circumscribed dulness, with total absence of respira- 
tory murmur over the dull area. The coexistence, however, of pul- 
monary and bronchial lesions does not explain the nature of the rela- 
tion between them. There is no doubt that, in cases of haemoptysis, 
blood coagulates in the bronchial tubes, and that in cases of pneumonia 
casts consisting of the same material as fills up the air-cells are pro- 
duced, but these seem to be quite distinct from the casts of plastic 
bronchitis, which probably originate in situ. 

Treatment. — Bronchitis is one of the commonest affections, at least 
of temperate climates, one of the most frequent sources of incapacity 
for useful work and for the enjoyment of life, and one of the most 



384 



DISEASES 0E THE RESPIRATORY ORGANS. 



fruitful causes of death. The treatment, therefore, is a matter of grave 
importance. It will be convenient to discuss it under different heads. 
Hygienic treatment. — This comprises the keeping of the patient in an 
equable and moderate temperature, not below 65° or 66°, and if possi- 
ble not very largely exceeding this, and preferably, therefore, confining 
him to the house or even to one room ; the maintenance of some degree 
of moisture of atmosphere; the use of hot baths, the Turkish baths, or 
the hot pediluvium; and the regulation of the diet according to the 
patient's capabilities and needs. Local treatment — Under this head 
may be included : first, treatment applied to the skin, inclusive of 
counter-irritation by mustard plasters, blisters, and the like, dry-cup- 
ping, and the abstraction of blood, either by leeches or the cupping- 
glasses; second, treatment applied to the mucous membrane, such as 
the inhalation of steam, either simple or medicated with some of those 
substances which have been enumerated in the treatment of laryngitis. 
Medicinal treatment. — The drugs which have been employed are various. 
Among expectorant or nauseating medicines, ipecacuanha, squills, and 
tartar emetic hold a very high place; stimulant drugs, such as the gum- 
resins and balsams, more particularly benzoin, tolu, guaiacum, and 
ammoniacum, are often valuable; and as closely related in action to 
these may be enumerated ammonia, senega, and the stimulant vegetable 
tonics. Sedatives and narcotics, such as opium, conium, belladonna, 
and hyoscyamus are of great importance; and in certain stages and in 
certain cases so also are sulphuric ether and lobelia. It must be added, 
lastly, that tonics and alcoholic stimulants are often, and especially in 
the later stages of the acute affection and in chronic cases, of extreme 
value. 

In ordinary mild bronchitis, little or nothing is needed beyond keep- 
ing the patient in a warm room, the inhalation of steam, the application 
to the chest of a mustard plaster, the use of the hot bath or pediluvium, 
the exhibition of small quantities of opium and ipecacuanha, and the 
relief of thirst and dryness of mouth by warm diluent drinks. 

In acute cases of greater severity, it may be necessary to abstract 
blood from the surface of the chest. This can only be needed when there 
is extreme difficulty and pain in breathing, and especially if at the same 
time there is reason to believe that the bronchial membrane is con- 
gested and swollen, and yielding but little secretion. The quantity of 
blood to be removed must be determined by the age and state of the 
patient, and by the effect of its removal. It is much better, however, 
to withdraw an adequate quantity at first than to repeat the operation 
over and over again. In such cases, too, counter-irritants and inhala- 
tion are of great value. As regards medicines, antimony or ipecacu- 
anha, in nauseating doses, combined, it may be, with squills, and above 
all, with small doses of opium, and frequently administered, is often 
very valuable. When the bronchial secretion becomes abundant and 
mucopurulent, these may still be continued, or may be replaced by the 
more stimulating forms of expectorant medicines. In this stage the 
combination of drugs recommended by Dr. Stokes, namely, ammonia, 
opium, and senega, is often very efficacious, as also are the balsams or 
gum-resins. When the patient suffers much from bronchial accumula- 



PNEUMONIA. 



385 



tion, the occasional employment of an emetic dose of ipecacuanha is 
often exceedingly useful. It must be added that, under similar circum- 
stances, the persistent use of tartar emetic, in pretty large doses, asso- 
ciated with alcoholic stimulants, is frequently of great value. In 
protracted cases, and during convalescence, tonics are called for, and 
good nutritious diet. Few drugs are more valuable than opium in the 
treatment of bronchitis; it relieves pain and distress, diminishes the 
irritability of the mucous membrane and the need for coughing, and 
probably also tends to reduce inflammation. At the same time its 
administration is often fraught with danger. It is best generally to 
give it in frequent small doses; and it is well to give it very cautiously 
or to withhold it entirely when the patient shows signs of imperfect 
aeration of blood, when his bronchial tubes are overloaded with mucus, 
or when he tends to ramble in his mind. 

In chronic bronchitis, especially when exacerbations are present, the 
treatment must in the main be the same as that of the acute affection. 
On the whole, however, the abstraction of blood, and the use of medi- 
cines calculated to depress the patient's strength, are not desirable. 
Counter-irritants, inhalation, stimulant medicines, tonics, and good diet 
are chiefly indicated. It is in these cases, too, that hygienic treatment 
is especially likely to be serviceable. The patient who is subject to a 
winter cough, increasing year by year in severity, and in whom em- 
physema and other such lesions are in progress, should dress warmly 
even in summer, should be careful not to expose himself to draughts 
or to the evening or early morning air, should give up those pursuits 
which expose him to the causes of bronchitis, and should pass his win- 
ters on . the South Coast, or on the shores of the Mediterranean, or in 
some other warm equable climate, or else confine himself to a room or 
a suite of rooms, well ventilated, but kept at a uniform and comfortably 
warm temperature. 



PNEUMONIA. 

Causation. — Inflammation of the substance of the lungs is, like 
bronchitis, due in the large majority of cases to the influence of cold 
and wet ; and it would seem that it may, under different circumstances, 
be caused either by brief exposure of portions of the heated surface of 
the body to a chill, or by prolonged exposure of the whole normally 
warm surface to a comparatively less degree of cold. It is especially 
common in temperate climates, and at those seasons (spring more 
especially) when the temperature is liable to great variations. It may 
also be caused by the spread of inflammation (whether originally due 
to cold or not) from other parts ; thus inflammation may extend to the 
lung-tissue from the primarily affected bronchial tubes, in cases of 
bronchitis, hooping-cough, measles, influenza, diphtheria, and the 
like; or from the pleura in cases of pleuritis, or, if the pleural cavity 
be obliterated by adhesions, from the chest-walls or the surrounding 

25 



386 



DISEASES OF THE RESPIRATORY ORGANS. 



viscera. And, again, it may be developed by the direct action of 
mechanical and other irritation, such as follows the inhalation of irri- 
tant gases, of particles of dust or other such substances, of solid bodies 
of larger size, of vomited matters, or even of water ; or may spring 
from the presence of emboli in the branches of the pulmonary artery, 
or of tubercles or clots in the tissue of the lungs. 

There are also many systemic conditions — especially the presence of 
pulmonary congestion or oedema, or the existence in the blood of specific 
poisons or effete matters — which favor the occurrence of pneumonia. 
And it is due to one or other or all of them, probably, that pneumonia 
is so common in the course of heart disease, kidney disease, typhus, 
and other of the infectious fevers, erysipelas, rheumatism, and other 
inflammatory disorders. It is very apt also to occur in persons ad- 
vanced in syphilis, or worn out by exhaustion, whether from disease 
or overwork. 

It must not be forgotten, however, that acute idiopathic pneumonia 
occurs with comparatively extreme frequency amongst those who seem 
to be in the best of health. This variety of the disease is met with at 
all ages and in both sexes; but it is more common in men than in 
women, and far more common among the working classes than others — 
facts which are explicable by the relatively greater exposure to the 
causes of pneumonia of those who have to earn a livelihood by the 
sweat of the brow. It may be added that a previous attack seems to 
predispose to subsequent attacks. 

Morbid Anatomy. — It will be convenient, in describing the morbid 
anatomy of pneumonia, to distinguish two forms, as has generally been 
done, namely, lobar and lobular pneumonia, or, as they are termed by 
German writers, croupous and catarrhal. These names are none of 
them unobjectionable, and it might be better to replace them by the 
words diffused and patchy, the type of the former variety being fur- 
nished by the idiopathic affection, that of the latter by the condition 
which is secondary to diseases of the air-passages. The two varieties, 
however, pass into one another. 

Lobar pneumonia commences with hyperemia of the small vessels 
which are distributed in the walls of the air-cells and bronchial passages, 
swelling and tendency to proliferation of the epithelial cells of these 
parts, and exudation of inflammatory lymph (serum, albumen, fibrin) 
and of the corpuscular elements of the blood. The air-cells and pas- 
sages which communicate with them consequently become gradually 
filled, and finally distended with exuded matter, the air which they 
contained gets gradually expelled, and the affected lung-tissue grows 
solid and heavy. If the morbid tissue be now examined microscopi- 
cally, the bloodvessels will be found to be distended with their cor- 
puscular contents, and the alveoli full of cells, some merely modified 
epithelial cells, with one, two, or more nuclei, other cells undergoing 
fatty change (in other words, granule-cells), and other cells having 
the characters of leucocytes or of pus-corpuscles, all blended together 
into a common mass by the presence in the intervals between them of 
either some amorphous glutinous cement, or a delicate fibrillated net- 
work. The ordinary process of inflammatory cell-proliferation has 



PNEUMONIA. 



387 



taken place, by means of which the epithelial cells have acquired a 
more or less distinct embryonic character; and to these escaped leuco- 
cytes have been added. With the progress of the disease the contents 
of the air-cells liquefy, and acquire more and more both the naked-eye 
and the microscopic characters of pus. The fatty degeneration which 
has been referred to may, either before or after the liquefaction of the 
contents of the air-cells, become general throughout the mass of cells, 
which may then, if not expectorated, gradually undergo absorption. 
The conversion of the inflammatory exudation into pus is occasionally 
followed by the breaking down of the lung-tissue here and there into 
abscesses ; and occasionally by the occurrence of gangrene. It may be 
added that inflammation of the lung, like inflammation of other parts, 
rarely if ever takes place without there being more or less abundant 
serous exudation into the surrounding uninflamed tissues; and, further, 
that pneumonic inflammation tends, like most other inflammations, to 
spread. 

The progress of pneumonia through its various phases is quite 
gradual ; nevertheless, there are at least three different stages in which 
it presents more or less obvious characteristic features. The first of 
these is commonly called the stage of engorgement, the second that of 
red hepatization, and the third that of gray hepatization. In the first 
stage the lung still contains air, though in diminished quantity ; it is 
deeply congested, exudes more moisture than natural, is increased in 
weight, and is more easily lacerable than healthy lung-tissue. This 
is the period of congestion and commencing proliferation ; and the 
lung in this stage is not easily, if at all, distinguishable from the lung 
which is the seat of simple hypostatic congestion. In the second stage 
the lung is consolidated ; it has lost its air, and its cavities are filled 
with coherent masses of cells ; it is distended to its full size, and its 
constituent lobules are distinctly mapped out upon the surface; on 
section it appears to be pretty dry and slightly granular (a condition 
still more noticeable on the surface produced by laceration), and it 
presents a peculiar marbled aspect, which is due to the intermixture 
of nearly colorless inflammatory deposit in the air-cells, of patches of 
congestion, and of the irregular slate-colored or black tracts which 
commonly stud the lung-tissue of persons who have reached adult 
age. The general hue of the lung is for the most part somewhat pale; 
there is probably, however, more decided congestion during life, and 
even after death the tissue is in some cases almost as deep in hue as 
that affected with pulmonary apoplexy. Sometimes, indeed, there is 
actual extravasation of blood. The lung-tissue is easily torn, and 
readily sinks in water. The third stage differs from the second, 
mainly in the assumption by the affected lung-tissue of a pretty uni- 
form opaque grayish, yellowish or greenish tinge, by the presence of 
considerable increase of friability, and by the ready exudation from the 
cut surface of thick, turbid, purulent fluid. In some cases the fluid is 
comparatively scanty ; in some it is so abundant that the lung is like a 
sponge saturated with pus. 

We have already mentioned the fact that there is generally, if not 
always, considerable oedema of the lung-tissue beyond the part actually 



388 



DISEASES OF THE RESPIRATORY ORGANS. 



inflamed. We may add that there is almost invariably a deposit of in- 
flammatory lymph on the pleural surface corresponding to the inflamed 
portion of lung, as well as upon the parietal pleura in contact with it, 
and that this tends to diffuse itself over the surface of the lung, and 
more especially towards its base, but is not generally attended with any 
large amount of serous effusion. 

Since pneumonia tends to spread, it naturally follows that different 
portions of affected lung often present well-marked differences of con- 
dition — that in fact we occasionally find all the stages of inflammation 
which have been detailed present at the same time in the same case. In- 
flammation may involve the lung to very various extents — thus it may 
be limited to a patch no larger than a walnut, or may include an entire 
lobe, or even the whole lung, and further, it may affect portions of 
both lungs. It is curious how often it is strictly limited by the fissures 
or fibrous septa which separate lobes, and how often it is accurately 
mapped out by the margins of lobules. As regards position, it seems to 
be a well-established fact that the right lung is more frequently affected 
than the left, and the lower lobe more frequently than the upper. In 
reference to this latter point, however, it may be observed that, if we 
divide the lung horizontally midway between apex and base, there will 
be at least some two or three times as much lung-tissue below as above 
the plane of division, and that hence, if all parts of the lung be equally 
liable to become inflamed, inflammation at the apex should be several 
times less frequent than inflammation of the base. The forms of pneu- 
monia which supervene on hypostatic congestion, which come on in 
the course of renal and cardiac disease, and which complicate pulmo- 
nary apoplexy and tubercle, differ little anatomically from that which 
has been here described. 

Lobular' pneumonia may be said to be par excellence the form of 
pneumonia which occurs in young children ; it is not, however, unfre- 
quent in older persons. In its best-marked form the lung is studded 
with pneumonic patches, varying in size from about that of a pea up 
to that of a filbert, consisting each of one or more pulmonary lobules, 
circumscribed by the interlobular septa, and separated from one another 
by a network of still crepitant, and it may be perfectly healthy, lung- 
tissue. The pneumonic patches may be in the condition of engorge- 
ment simply, in which case their character may possibly fail to be 
recognized, or they may present the ordinary features of red or of gray 
hepatization. Further, by extension of disease, neighboring patches 
may coalesce, and thus an extensive tract of lung-tissue become in- 
volved. Lobular and lobar pneumonia here pass into one another. 
True lobular pneumonia is always secondary to the blocking up of the 
air-passages, and especially those of capillary size; it may be immedi- 
ately excited either by the gradual extension of the inflammatory pro- 
cess from the tubes to the air-cells, or by the entrance therein during 
inspiration of the inflammatory products of these tubes, which then 
irritate the parts to inflammation, But, whatever the cause, we find 
in the inflamed parts not merely overgrown and modified epithelial 
cells, but also, according to the stage of the disease, granular and em- 
bryonic cells in greater or less proportion. The connection of lobular 



PNEUMONIA. 



389 



pneumonia with, obstruction of tubes is further shown by the facts that 
lobular collapse is often associated with it, and that then the collapsed 
and pneumonic conditions may often be seen to pass into one another 
by gentle gradations. 

Closely related to catarrhal lobular pneumonia is the disseminated 
pneumonia due to obstruction of small branches of the pulmonary 
arteiy, either by embolism or thrombosis, or in the course of pyemia. 
In these cases, as in the other, the affected patches are usually of small 
size, and limited by the margins of lobules. But there is greater 
variety of result, especially in pyemia, in which disease, while the 
patches sometimes present simple engorgement, or red or gray hepa- 
tization, they not unfrequently are the seat of hemorrhage, or undergo 
rapid suppuration or gangrene. Lobular pneumonia is generally best 
marked towards the basal portions of the lungs, and the patches which 
are superficial are often each the centre of a patch of pleural exu- 
dation. 

In all forms of pneumonia, even such as are not of bronchitic origin, 
there is a tendency towards the development, sooner or later, of more 
or less bronchitis. But, apart from this, there is a marked tendency, 
early in the course of pneumonia, to the effusion into the tubes from 
the inflamed air-cells of a transparent, very viscid fluid, uniformly 
stained with blood, and containing corpuscular elements; and, in some 
rare cases, this effusion, like that in the air-cells, whence it is derived, 
undergoes coagulation in the bronchial tubes, which thus become filled 
to a greater or less extent with casts consisting of coagulated fibrin and 
of corpuscles. 

Notwithstanding the frequency with which pneumonia proves fatal, 
it does not very often go beyond the third of the stages which we have 
described; sometimes, however, abscesses form, sometimes gangrene 
takes place, and sometimes the pneumonia lapses into a chronic condi- 
tion. Pneumonic abscesses are usually of small size and irregular 
form ; and in some cases, especially when they are developed in con- 
nection with lobular pneumonia, the terminal bronchial tubules are 
primarily affected, their parietes become destroyed, and the abscesses 
taking their course assume a dendritic character. Gangrene very rarely 
indeed occurs in the course of simple idiopathic pneumonia'; it is 
chiefly met with in those cases in which the pneumonia is secondary 
to or complicated with some other affection. It is characterized by the 
breaking down of the lung-tissue into a fetid dirty greenish-yellow 
pulp, and by more or less greenish discoloration of the consolidated 
tissues around. Not unfrequently the latter are eedematous and pre- 
sent a slightly translucent aspect. The gangrenous condition may 
involve an extensive tract of lung-tissue or scattered patches only, or 
even a single small patch. If it be recent at the time of post-mortem 
examination its margins will be found ill-defined ; if it have existed 
for some length of time the gangrenous cavity will be bounded prob- 
ably by a well-defined edge. Of chronic pneumonia we shall speak 
at length hereafter. 

Of the associated morbid phenomena of pneumonia there are several 
that call for mention, if not for detailed description. We have 



390 



DISEASES OF THE RESPIRATORY ORGANS. 



adverted to the coexistence with pneumonia of pleurisy and bronchitis ; 
but besides these, we very frequently observe, early in the disease, an 
herpetic eruption on, or in the neighborhood of, the lips ; more or less 
jaundice without obvious hepatic disease ; intestinal congestion, with 
sometimes membranous patches on the mucous surface of the large 
intestine ; and inflammation of the bronchial glands. And it must be 
added that the same conditions which give rise to pneumonia occa- 
sionally give rise at the same time to inflammation of other organs. 
Thus we sometimes find associated with pneumonia inflammation of 
the brain, kidneys, bowels, or pericardium. It is common, after death 
from pneumonia, for the right side of the heart to be full of fibrinous 
coagulum which is prolonged into the pulmonary artery, while the left 
side of the heart is contracted and almost empty. 

Symptoms and Progress. — Idiopathic pneumonia is frequently 
ushered in with a day or two of feverishness or undefinable feeling of 
illness. This is generally succeeded by a sudden and severe rigor, or 
by a succession of rigors, or in children by an attack of convulsions — 
phenomena which are attended with a rapid and considerable elevation 
of temperature, and the usual symptoms of more or less severe inflam- 
matory fever. The specific signs of the pulmonary affection declare 
themselves either immediately or in the course of the next four-and- 
twenty hours, or in rare cases may be delayed for a day or two. They 
consist in rapidity and shallowness of breathing, with sometimes very 
manifest dyspnoea ; dorsal decubitus ; cough, attended soon with blood- 
stained glutinous sputum ; probably pain in the affected side on 
drawing a deep breath ; and, according to the stage which the pul- 
monary affection has reached, fine crepitation, or dulness with tubular 
breathing, and augmented bronchophony and vocal fremitus. While 
these local conditions are in progress, the patient's febrile state con- 
tinues ; his skin is hot and dry or perspiring, his tongue furred, his 
pulse accelerated ; jaundice is apt to come on, and diarrhoea; his urine 
is scanty and probably albuminous; at the same time, probably, he 
suffers from more or less hebetude, with delirium, which comes on 
especially at night. The further progress of the case will vary accord- 
ing to its severity. In some cases, after two or three days of illness, 
the patient's temperature falls, his other symptoms subside, and con- 
valescence is established. In other favorable cases the commencement 
of convalescence may be delayed to the end of a week, ten days, or 
even a fortnight ; and the amendment may then be either sudden or 
gradual. In cases which end fatally, death may occur at any period 
in the course of the disease, even in apparent convalescence, and is 
due, as a rule, either to asthenia or to gradual asphyxia, or to a com- 
bination of these conditions. 

We will discuss seriatim some of the more important of the phe- 
nomena which attend pneumonia. 

The respirations are usually hurried and shallow, and may vary in 
rate from the normal up to 50 or 60 in the minute and upwards ; when 
very rapid they are usually attended with a sucking sound in the 
mouth, and expansive movements of the alse nasi ; there is sometimes, 



PNEUMONIA. 



391 



but by no means always, more or less severe dyspnoea, and generally 
there are signs of breathlessness when the patient attempts to speak. 

There is almost always more or less cough, which is sometimes very 
troublesome and even paroxysmal ; but it is attended with no charac- 
teristic sound or other quality. At first it is dry, but it is soon 
attended with the expectoration of transparent and exceedingly viscid 
mucus, tinged with the coloring matter of the blood. This is usually 
said to have a rusty tint, and often indeed has ; but it varies in color 
between a pale saffron and a bright vermilion. In the latter case it 
may be mistaken, on hasty inspection, for pure blood. After the 
expectoration has retained this character for a few days, it loses its 
sanguineous tint and becomes somewhat opaque and greenish, acquires 
in fact a muco-purulent character, and then gradually diminishes in 
quantity. In some cases, instead of undergoing this latter, which may 
be regarded as the normal change, it acquires a deep purplish or 
reddish-brown tint and at the same time a more watery consistence. 
This form of sputum has been likened to prune-juice, and is generally 
an indication not only of increased congestion and escape of blood, but 
of the access of the third stage, and of an unfavorable issue. In some 
cases, again, the expectoration becomes distinctly purulent, or may be 
attended with the horrible fetor which usually indicates pulmonary 
gangrene. The quantity and quality of the expectoration vary re- 
markably in different cases. In some there is absolutely none from 
first to last; in some there may be no more than one or two rusty- 
colored sputa ; in others the sputa may never present the characteristic 
tint; while in others again the discharge may present the normal 
sequence of variations, and in either case may be extremely profuse. 
Pneumonic expectoration is characterized by the presence of a super- 
abundance of common salt, and contains a considerable quantity of 
mucus and of albumen. 

There is considerable variety as to the presence and degree of tho- 
racic pain. In some cases there is no pain whatever ; in some there is 
a mere sense of heat ; in some, however, the patient has a severe stitch 
whenever he coughs or draws a deep breath. This pain is pleuritic in 
character, and doubtless due to the coexistence of pleurisy. 

In the first stage of the disease the most characteristic auscultatory 
phenomenon is the. presence of minute crepitation, which may be audi- 
ble during the whole of inspiration, sometimes during expiration as 
well, and not unfrequently only at the end of a deep inspiration, such 
as that which precedes a cough. In association with this there may be 
no change on percussion, or there may be high-pitched resonance or 
bruit de pot fele. The second stage is marked by the supervention of 
dulness over the consolidated portion of lung, with increase of vocal 
fremitus ; cessation of fine crepitation with the development of well- 
marked tubular breathing, and the corresponding whiffing character of 
the cough and voice ; bronchophony and in some cases pectoriloquy. 
There may also be sharp metallic crepitation or rhonchus. In some 
cases, probably when the bronchial tube leading to the consolidated 
portion of lung is completely obstructed, there may be, over the affected 
region, total absence of respiratory and vocal sounds and of bronchoph- 



392 



DISEASES OF THE RESPIRATORY ORGANS. 



ony. It need scarcely be pointed out that, in consequence of the co- 
existence of pleurisy, it is common in pneumonia to get friction-son nds 
mixed up with those due to the pneumonia itself, and possible even for 
the pneumonic sounds to be suppressed or replaced by the phenomena 
indicative of pleurisy. At a later stage, when lung-tissue is breaking 
down, or resolution is taking place, the tubular breathing becomes re- 
placed by a kind of coarse crepitation, to which the name of crepitatio 
redux has been given. This gradually gives way to the ordinary signs 
of bronchitis. It may be added that, when the pneumonic lung is con- 
solidated, the movements of the portion of the side corresponding to it 
become impaired, and the resistance on percussion manifestly increased ; 
and, further, that pneumonia may be present, deepseated in the lung, 
or limited to its diaphragmatic or inner surface, and thus altogether 
escape detection by auscultation or percussion. Some degree of dulness 
on percussion usually persists long after the disappearance of the other 
local signs of pneumonia. 

The cardiac pulsations are always increased in frequency during the 
febrile stage of the disease, but rarely increased proportionately to the 
respirations. Often, indeed, their ratio, instead of being about 4 to 1, 
sinks to 2 or 1 J to 1. In adults the pulse may range from 80 or 90 
up to 120; in children it is generally more rapid, and may rise to 200 
and upwards. Extreme rapidity is generally associated with feebleness, 
and not unfrequently with irregularity, and is hence to be regarded as 
an unfavorable sign. In the beginning the pulse is often somewhat 
full and strong, sometimes full and dicrotous ; later on, however, it 
always becomes more or less feeble and dicrotous. During convalescence 
it may fall below the normal frequency. While pneumonia is in prog- 
ress the systemic veins are apt to become more or less overloaded, and 
the surface may assume a dusky hue. The blood always presents a 
large excess of fibrinogen. 

The tongue is more or less thickly coated, and in some cases tends 
to become dry and brown, and sordes may accumulate upon the teeth. 
Thirst is pretty constant, and there is loss of appetite. Sometimes the 
patient suffers from sickness. The bowels vary; sometimes they are 
not particularly affected throughout the disease; sometimes they are 
constipated ; sometimes, on the other hand, there is more or less profuse 
diarrhoea, and this may be dysenteric in character. The occurrence of 
jaundice during the progress of pneumonia is neither uncommon, nor 
very important. It is said to occur most frequently in those cases in 
which the right lower lobe is affected. There is, however, no more 
necessary connection between right pneumonia and jaundice than be- 
tween left pneumonia and it. 

The urine is scanty, dark-colored, and of high specific gravity, con- 
taining a diminished quantity of chloride of sodium and a great excess 
of urea and uric acid, with a tendency to the deposition of urates. 
Sometimes it contains also a little albumen, and hyaline, granular, or 
epithelial casts. During convalescence it becomes much more abundant, 
pale, of low specific gravity ; and the urea undergoes diminution, while 
the chloride of sodium increases. 

The face is more or less flushed in the early period of pneumonia, 



PNEUMONIA. 



393 



and may be at the same time somewhat livid; the skin is frequently 
hot and dry; but profuse perspirations are not uncommon during the 
progress of the disease, and generally attend its decline. An herpetic 
eruption about the lips and alse nasi is of very common occurrence. 

The patient at first complains of headache and usually also of gen- 
eral febrile pains. He is often drowsy, yet apt to be restless, especially 
at night-time. Delirium often comes on early, at first being limited 
to the night, but subsequently becoming more or less constant. In 
some instances, especially in the case of persons who have been given 
to drink, the nervous symptoms very soon assume all the characters of 
delirium tremens. And again, patients, not otherwise obviously 
affected in the mind, occasionally become suddenly and violently mani- 
acal, the paroxysm possibly abating as suddenly as it arose. In fatal 
cases delirium is apt to pass into coma. There is often more or less 
tremulousness and subsultus in severe cases, with loss of control over 
the bladder and rectum. 

The temperature in pneumonic patients rapidly rises from the time 
of invasion, so that within a few hours, at most perhaps twelve, it has 
almost attained its maximum; this may vary from 100° up to 106°, 
or even more. Thenceforward the temperature remains high, probably 
increasing somewhat, with morning remissions and evening exacerba- 
tions, until the time of commencing convalescence, when it either sud- 
denly or gradually falls. In the former case the temperature may sink 
to the normal or below it in the course of twenty-four hours. Occa- 
sionally in fatal cases the temperature rapidly rises before death. 

The symptoms of uncomplicated idiopathic pneumonia are collec- 
tively so characteristic of the disease that it is almost impossible to 
mistake their significance. The affections, other than those of the 
respiratory organs, with which it is most liable to be confounded, are 
typhus and enteric fevers. No real difficulty, however, can arise un- 
less the specific characteristics of these fevers be in abeyance, and they be 
at the same time (as they often are) complicated with secondary pneu- 
monia. It is altogether different, however, in respect of the various 
forms of intercurrent or secondary pneumonia, and of the lobular va- 
riety of the disease. These creep on, for the most part, insidiously in 
the course of other grave affections, which have already probably pro- 
duced serious pulmonary symptoms, such as dyspnoea, cough, expectora- 
tion of serous, mucous or bloody sputa, lividity of surface, and proba- 
bly other indications of embarrassed circulation and of carbonic acid 
poisoning; their onset is not usually marked by rigors or anything 
equivalent to rigors, nor is their progress usually attended with the 
high febrile disturbance which characterizes the idiopathic variety ; 
and, again, they are not often accompanied by labial herpes, or by 
jaundice, and very often there is, excepting towards the close of the 
disease, an entire absence of delirium. The supervention of these 
forms of pneumonia may be suspected in patients suffering from the 
various diseases which are apt to be complicated by them when their 
symptoms, and especially those referable to the respiratory organs, be- 
come aggravated ; but they can only be positively determined by 
careful physical investigation of the condition of the thoracic organs. 



394 



DISEASES OF THE RESPIRATORY ORGANS. 



It must not be forgotten, however, that lobular pneumonia may be 
present to a considerable extent without producing either the charac- 
teristic d ulness, the tubular breathing, or other specific phenomena of 
the more uniformly diffused variety of the disease. The auscultatory 
and percussive phenomena indeed may differ little, if at all, from those 
which attend capillary bronchitis. 

The breaking down of portions of lung-structure which occasionally 
attends the later stages of pneumonia does not reveal itself by any 
special sign, unless the cavities be such as, from their size or position, 
to give rise to characteristic auscultatory phenomena. In rare cases 
such abscesses, burst into the pleura, or (the lung being adherent) per- 
forate the thoracic walls, or they form sinuses running down behind 
the peritoneum, and opening ultimately into the colon or some of the 
hollow viscera of the pelvis. -The occurrence of gangrene is usually 
revealed by the disgusting fetor of the breath, especially during the 
processes of coughing and expectoration, and in a less degree by the 
look and smell of the sputa. Here also the cavities due to the destruc- 
tion of lung-tissue may perhaps admit of detection. The supervention 
of gangrene is often attended with marked depression of the vital 
powers, with, in tact, more or less obvious symptoms of collapse. 

Pneumonia is always a disease of considerable gravity. Still, in its 
idiopathic form, it comparatively rarely kills, unless the portion of 
lung involved be very extensive, or unless both lungs be attacked, or 
except in the case of persons advanced in years, or of those whose con- 
stitutions have been injured by long-continued bad habits, overwork, 
or disease. The secondary form of the disease, and especially the lobu- 
lar variety, on the other hand, are exceedingly fatal, and may be in- 
cluded among the chief immediate causes of death in the various mala- 
dies which they complicate. 

Treatment. — There are few diseases for which so many opposite plans 
of treatment have been employed with reputed success as for pneumo- 
nia. It is a disease, too, which, more perhaps than any other, has on 
this very account been appealed to in proof of the change of type of 
disease. From the time of Laennec to about the middle of the present 
century almost implicit reliance was placed in the combined use of 
bloodletting, antimony, and mercury. Since then, especially dating 
from the time of Dr. Todd, these remedial agents have been to a very 
large extent discarded, and have become replaced by the free exhibi- 
tion of alcoholic stimulants. Many, indeed, now regard all medicinal 
treatment as of little or no importance ; and it is quite certain that a 
large number of even severe cases recover perfectly if left to nature 
and the nurse. 

In the majority of cases of the idiopathic disease it is probably quite 
sufficient to keep the patient in bed in a comfortable, well-ventilated 
room, of medium temperature ; to relieve thoracic pains with mustard 
plasters and the like ; to assuage febrile thirst by the exhibition of 
soda-water, orangeade or lemonade ; to support strength by the frequent 
administration of milk or gruel, or some equivalent nutritious fluid; 
and to relieve, from time to time, by simple measures, diarrhoea or 
constipation, and other remedial derangements of the various organs ; 



PLEURISY. 



395 



and then, as convalescence comes on, to give vegetable tonics, and 
gradually to improve the diet in respect both of quantity and quality. 
It is doubtless true, however, that, in many cases, the above plan of 
treatment may be judiciously supplemented by other measures. Bleed- 
ing from the arm, or the local abstraction of blood from the chest by 
cupping or leeches, is certainly followed by relief to symptoms when 
employed early in cases in which there is high fever and much dysp- 
noea. We believe that bleeding from the arm is more efficacious than 
the other methods of bleeding, but in any case it is better to remove 
sufficient blood at a single operation than to be called upon to repeat it. 
Counter-irritants and detergents are often serviceable at a later period 
of the disease, or at the beginning of slight cases in which bleeding is 
not deemed necessary. They relieve pain, and sometimes diminish 
difficulty of breathing. Dry cupping is of especial value. Some phy- 
sicians think it well to keep the affected side invested in a large poul- 
tice or a layer of cotton-wool ; others prefer the application of ice-bags 
or cold compresses. We do not think that any benefit accrues from 
the former plan, but the latter probably has some beneficial influence. 
Expectorants, such as ipecacuanha, in small doses, may possibly aid 
those cases in which there is frequent and troublesome cough, with 
difficulty of expectoration ; and, under the same circumstances, the ad- 
dition of a small quantity of opium may be serviceable. 

When the pulse becomes very quick and weak, and delirium is es- 
tablished, especially if the patient present the general symptoms of 
delirium tremens, diffusible stimulants, such as ammonia, and alco- 
holic preparations, in quantities to be determined by their effects, are 
indispensable. It may be added that, with the object of reducing tem- 
perature, various agents have been recommended; and possibly one or 
other of them may be used with advantage ; among these may be enu- 
merated cold baths, quinine in large doses, veratria, digitalis, and aco- 
nite. The supervention of suppuration or gangrene is a special reason 
for the maintenance of the patient's strength by nutritious food, stimu- 
lants, and tonic medicines. Opium is often of great service, but should 
not be given, or should be given very cautiously, when the patient is 
suffering from dyspnoea, and from insufficient aeration of the blood. 
The treatment of secondary pneumonia merges in the treatment of the 
disease it complicates. Its supervention, however, is on the whole a 
plea, not for depletion, but for the opposite plan, namely, the use of 
stimulants and of nourishment. 



PLEURISY. (Pleuritis.) 

Causation. — Pleurisy is either idiopathic or dependent on constitu- 
tional causes ; or it is the result of local irritation. The former class 
includes pleurisy directly arising from exposure to cold — the form of 
pleurisy which corresponds to idiopathic pneumonia and bronchitis — 
and that which takes place in the course of acute rheumatism. Among 



396 



DISEASES OF THE RESPIRATORY ORGANS. 



the latter class may be enumerated the form of pleurisy due to the ex- 
tension of inflammation from inflammatory and other affections of the 
lungs, or of the thoracic parietes ; that due to mechanical injuries, 
more especially to the rupture into the pleura of pulmonary cavities, 
or of abscesses of the liver or other neighboring organs ; as probably 
also the pleurisy which is so commonly associated with the progress of 
pulmonary phthisis and thoracic carcinoma. In addition to the forms 
of pleurisy here enumerated must be mentioned those which become 
developed in the course of small-pox, scarlatina, enteric fever, pyaemia, 
renal disease, and heart disease, and in respect of which these several 
diseases act variously, sometimes as the exciting, sometimes, and per- 
haps more frequently, as the predisposing causes. 

Morbid Anatomy. — Inflammation of the pleura, like that of all other 
serous membranes, commences with hypersemia of the bloodvessels, 
proliferation of the protoplasmic elements of the tissues, more especially 
of the epithelium, and effusion into the serous cavity of inflammatory 
lymph, comprising a variable but pretty considerable quantity of albu- 
men, fibrin, and corpuscular elements. The last two for the most part 
remain adherent to the serous surface, forming the so-called "false 
membrane;" the fluid, containing albumen, fibrinogen, and a variable 
proportion of corpuscles, accumulates within the serous cavity. The 
inflammatory process, therefore, combines three elements, which may 
conveniently be considered independently of one another, namely, first 
inflammatory hyperemia and infiltration of the serous and subserous 
tissues ; second, the formation of a false membrane ; and third, the 
effusion of serum. 

The first of these elements is the first in order of development ; but 
it rarely attains a high degree or forms a prominent item in the col- 
lective inflammatory changes. There is always, however, more or less 
obvious infiltration, its amount having some relation to the intensity 
of the inflammatory attack; and this not unfrequently extends into the 
connective tissue round about, as, for example, along the interlobular 
septa of the lungs, into the tissue of the mediastina, and into that of 
the diaphragm and of the thoracic parietes. And thus it occasionally 
happens that the superficial stratum of lung-tissue becomes involved, 
that the diaphragm and intercostal muscles become affected, and that 
the inflammation, commencing in one serous cavity, extends to those 
which are in its immediate vicinity. 

The effusion of inflammatory lymph always commences at a very 
early period. At first it constitutes an exceedingly thin, granular, but 
more or less coherent pellicle, the presence of which renders the serous 
surface obviously rough to the finger and deprives it of its polish. 
This gradually extends in area and increases in thickness, becoming 
at the same time more and more obviously yellow and translucent. 
The thickness which the false .membrane may attain varies roughly 
from that of a mere film up to half an inch or even an inch. The 
character of its surface presents numerous varieties, which depend 
partly on the tendency of the lymph itself to be deposited in the form 
of a network, partly on the attrition to which it is exposed during the 
movements of the opposed surfaces upon one another, and partly on its 



PLEURISY. 



397 



stickiness. It thus acquires a more or less irregular ribbed, villous, or 
retiform character. When the opposed surfaces of an inflamed pleura 
are separated by fluid effusion it often happens that trabecule and 
bands or septa of false membrane pass irregularly between them. The 
attached surface of the false membrane is always closer in texture and 
tougher than the free surface, and becomes with age more and more 
firmly united to the proper serous membrane, with which indeed it 
ultimately becomes incorporated. It is here, too, that organization, 
with the formation of new bloodvessels, commences — a process which, 
if the case go on favorably, ultimately pervades the entire thickness of 
the false membrane, and leads to the blending of the opposed layers, to 
their conversion into connective tissue, and to the obliteration of more 
or less of the pleural cavity. 

The fluid effusion is very variable in quantity relatively to the other 
two elements of the inflammatory process. It is difficult in many cases 
to account for this fact, but occasionally it is explicable in some degree 
on mechanical grounds. In the first instance the fluid is transparent, 
yellowish or greenish, presenting probably flakes of lymph floating in 
it. In many cases it retains this character throughout, but in some it 
becomes turbid or opaline, and deposits a little milky sediment on stand- 
ing. Occasionally it acquires the characters of ordinary pus. It may 
be added that blood is sometimes effused either from rupture of the 
new-formed vessels of the false membrane or from ulcerative destruction 
of the subjacent lung-tissue; that gas is occasionally present, an occur- 
rence due either to an external wound or to some communication be- 
tween the lung or intestine and the pleura; and, lastly, that the puru- 
lent contents occasionally become very fetid. The quantity of fluid 
effused may vary from almost zero up to two or three quarts. 

In a large number of cases especially those in which the pleurisy is 
due to the extension of inflammation from subjacent parts — as it is, for 
example, when it arises in the course of peritonitis, pericarditis, lobar 
pneumonia, or the various forms of disseminated pneumonia — the effu- 
sion of serum is very scanty, and the lymph forms a thin film which 
may be limited to the area primarily involved, and that opposed to it, 
or may creep gradually over the whole pleural surface. Moreover it 
is in such cases far less liable to spread from below upwards than from 
above downwards; and even in slight cases with little effusion it is 
common for the inflammatory products (solid as well as fluid) to sub- 
side to the most dependent part of the pleural cavity and to accumulate 
there. In other cases, again, and more particularly, perhaps, in the 
idiopathic form of the disease, and in those varieties of it which attend 
on small-pox and other eruptive fevers, or tuberculosis, and in that due 
to perforation of the pleura by abscess, effusion takes place rapidly and 
copiously. The effects of the accumulating fluid are the distension of 
the pleural cavity, the compression of the lung, and the displacement 
in different degrees of the surrounding organs. As the fluid rises in 
the thorax, more and more of the lung, commencing with its lower 
part, has its air squeezed out of it. Subsequently, perhaps, the whole 
organ suffers, and consequently becomes remarkably reduced in size, 
and compressed into the upper part of the angle between the vertebrae 



398 DISEASES OF THE RESPIRATORY ORGANS. 

and ribs. There, in fact, it may lie concealed from view by a layer of 
lymph continuous with that lining the thoracic parietes; and the un- 
skilled pathologist might readily assume that the lung had undergone 
total destruction. If the lung have been the seat of consolidation, or 
if it have been previously bound to the parietes here and there by old 
adhesions, or if the distension of the pleura with fluid be incomplete, 
the compressed lung will probably hang more or less irregularly into 
the pleural cavity. The accumulation of fluid causes, in addition to 
compression of the lung, displacement of the heart and mediastinum 
towards the opposite side of the chest (especially observable when the 
left pleura is affected), depression of the diaphragm, and expansion of 
the outer parietes of the thorax, with widening and probably bulging 
of the intercostal spaces. 

When suppuration takes place (an occurrence of special frequency in 
the pleurisy of small-pox, scarlet fever, measles, pyaemia, of women 
who have just undergone childbirth, and in that from perforation), all 
the phenomena just described naturally ensue ; but to them will proba- . 
bly be superadded others due to the presence of pus. The empyema 
or abscess sooner or later tends to point. Not unfrequently it opens into 
the lung; sometimes it makes its way through the thoracic parietes, 
forming, in the first instance, a sinus between the ribs, which probably 
become to a greater or less extent exposed and carious, then an accu- 
mulation between the ribs and the integuments, which, gradually 
enlarging, may develop, ere an external opening takes place, into a 
large superficial abscess. The route which such a sinus may take, and 
the point at which it may present, are liable to great variations. Thus 
sometimes the abscess appears at the apex of the thorax, and even above 
the clavicle; sometimes it opens in the loin below the level of the 
twelfth rib. Much more frequently, however, it occupies some interme- 
diate position. In rare cases the empyema perforates the diaphragm 
and may then take the course of a renal or psoas abscess, and finally 
open in any of the situations which these latter abscesses affect. 

The ultimate consequences of pleurisy are various. In the great 
majority of cases the fluid accumulation undergoes absorption, the par- 
tially-compressed lung recovers itself, and the effused lymph becomes 
slowly converted into a kind of cicatricial connective tissue, which re- | 
mains permanently. This may ultimately form a mere white opacity 
upon some portion or portions of the pleural membrane ; or, what is 
far more common, may result in the formation of adhesions between 
the opposed surfaces. These latter may consist in a mere intervening 
film of connective tissue, or in groups of filaments and bands of various 
lengths, or in tissue as close, dense, and tough as cartilage or tendon, 
which in process of time may become the seat of calcareous deposit. 
Adhesions may be limited to one or two points only, or may be -more 
generally but irregularly distributed, or may involve the whole extent 
of the pleura, the cavity of which then ceases to exist. 

When, however, the lung has been long compressed by fluid effusion 
(whether serous or purulent), and rendered entirely airless, especially 
if at the same time it has been covered with a thick dense layer of false 
membrane, the absorption or removal of the fluid is probably attended 



PLEURISY. 



399 



with little or no restoration of the lung; and the space which that 
organ occupied becomes filled up by the falling in of the surrounding 
parts. The mediastina and the heart are drawn over towards the af- 
fected side, the corresponding half of the diaphragm rises, carrying 
with it the stomach or the liver, as the case may be ; the ribs are re- 
tracted and at the same time approximated; the shoulder falls, the 
spine bends in the same direction, and the patient's carriage undergoes 
a corresponding change. At the same time the adhesions probably re- 
main abundant and thick, and sometimes oedematous. In many cases, 
on the other hand, when compression has been less complete, or the 
adhesions are less strong, convalescence, even after an extreme amount 
of pleural effusion, is attended with more or less restoration of the af- 
fected lung — an event which often requires considerable lapse of time 
for its completion. In some such cases, when death has ensued before 
the entire removal of the fluid, the lung is found to be invested in a 
fenestrated layer of pretty dense false membrane, which by the general 
pressure it exerts renders the organ irregularly rounded, while the 
fenestra? permit of irregularly distributed lobulated protrusions of crep- 
itant lung-tissue. 

An empyema may, after the discharge of its contents, be followed by 
any of the consequences above enumerated ; but, like other deepseated 
abscesses, its cavity often fails to become wholly obliterated, and a 
sinus consequently remains which continues to discharge for months, 
years, maybe for life. This tendency for an empyema to remain open 
may in some cases be traceable to a carious condition of the ribs. On 
the other hand, circumscribed collections of pus here as elsewhere some- 
times dry up into caseous masses. 

Before concluding this part of the subject it may be well to point out 
that inflammation may attack a pleura already partially or wholly ob- 
literated by adhesions. In the latter case the consequences will probably 
be congestion, infiltration, and thickening of the pre-existing false mem- 
brane. In the former case the effused fluid (serum or pus) will occupy 
either a more or less definitely circumscribed space or the whole pleural 
cavity, divided by bands and septa into a series of intercommunicating 
loculi. Such circumscribed accumulations of pus or serum are occa- 
sionally met with in the interlobular fissures, or between the diaphragm 
and base of the lung, or between the inner aspect of the lung and the 
mediastina, — situations in which they often escape recognition during 
life. 

/"^ Symptoms and Progress. — The symptoms of pleurisy present great 
variety, both in intensity and in kind — the differences being mainly due 
to differences in the extent, position, and intensity of the inflammation, 
in the circumstances under which it is developed, in the diseases with 
which it is associated, and in the stage at which it has arrived. The 
specific symptoms nevertheless are simple enough, and, in addition to 
the signs furnished by percussion and auscultation, principally comprise 
thoracic pain during respiration, dyspnoea, and inflammatory fever. 

The invasion of idiopathic pleurisy is far from uniform in its symp- 
toms. In some cases the patient complains only of a little feverishness, 
loss of appetite, and general malaise, together with a stitch or pain in 



400 



DISEASES OF THE RESPIRATORY ORGANS. 



one side when he breathes deeply, or coughs, or twists his body, or 
moves the corresponding arm; and he may continue to follow his ordi- 
nary avocation until, in the course of a week or two, or more, he is 
restored to health, or until, at the end perhaps of an equally long time, 
increasing illness and difficulty of breathing make him consult a medi- 
cal man, who may possibly then find the implicated side distended with 
fluid. In other cases the patient is suddenly seized with rigors, or (and 
this may occur even in adults) an epileptiform attack, followed by high 
febrile symptoms and the characteristic stitch. And in others, again, 
after he has complained for a clay or two of some degree of feverishness. 
and pain in the side, the symptoms, both local and febrile, assume sud- 
den intensity. 

But, however the disease comes on, whether with rigors or with none, 
whether slowly and insidiously or by sudden onset, it rarely happens, 
unless it be suppurative from the beginning or dependent on the pres- 
ence of some blood-poison, that the temperature rises above 102°; 
often, indeed, it does not exceed 100°, and it may be scarcely above 
the normal. The condition of the pulse and the other general symp- 
toms have some relation with the temperature. The pulse is generally 
full and vibratile or dicrotous, and somewhat increased in frequency, 
the skin is hot, the tongue more or less furred, the appetite impaired, 
the thirst increased, the urine scanty and high-colored, and the bowels 
confined. There are probably also headache and general febrile pains. 
From the beginning the patient has a stitch, which is usually referred 
to the mammary region, and the presence of which renders deep inspi- 
ration and all thoracic movements painful, so that the respiratory acts 
become hurried and shallow and perhaps irregular, and attended fre- 
quently with an expiratory groan, and the patient avoids all unneces- 
sary movement. There is usually also some tenderness on pressure 
and on percussion of the affected side. 

While these symptoms are present and the pleurisy remains in the 
so-called " dry " stage, percussion may perhaps reveal some little dul- 
ness at the base of the pleural cavity, and auscultation may detect, here 
or elsewhere, some variety of friction-sound. Cough is often absent, 
and, when present, dry, or attended only with a little frothy expectora- 
tion. It is rarely severe, but is sometimes paroxysmal and troublesome, 
and always painful. 

As effusion increases, the pleuritic stitch for the most part diminishes, 
and at length may wholly disappear. At the same time the febrile tem- 
perature and general symptoms of illness may remain at the same level, 
or undergo some diminution. Dyspnoea may or may not increase ; and 
it is important to know that the effusion of sufficient fluid to distend 
the pleural cavity is in some cases attended with little or no obvious 
dyspnoea so long as the patient remains at rest. On the whole, how- 
ever, dyspnoea increases with increase of fluid accumulation ; and the 
patient not only breathes rapidly, but suffers from much distress and 
anxiety, becomes pale or livid, even to cyanosis, and presents all the 
phenomena of slow asphyxia. The presence of fluid in the pleura is 
indicated by dulness on percussion up to the level at which the fluid 
stands — the level, in many cases, distinctly varying, in relation to the 



PLEURISY. 



401 



different points of the thoracic walls, with the patient's movements; 
by suppression of vocal fremitus over the dull part; and by absence of 
respiratory sounds, or presence in some cases of faint tubular sounds, , 
over the same region. Moreover, segophony is usually audible about 
the angle of the scapula. Sometimes, also, friction-sounds are recog- 
nizable above the level of dulness, and, as has been pointed out, high- 
pitched resonance and the bruit de pot fele may often be observed over 
the yet healthy portion of the side. 

When the effusion fills the pleural cavity, and the lung is wholly 
compressed, dulness of the side, with absence of vocal fremitus, becomes 
general, and both segophony and respiratory sounds cease. The last, 
however, may generally still be heard about the apex, in front and 
behind, and thence downwards behind, between the scapula and the 
spinous processes of the vertebra?. But, in addition to these phe- 
nomena, the heart becomes displaced, the diaphragm thrust down, the 
side distended and almost immovable, with dilated intercostal spaces, 
over which, by careful manipulation, fluctuation may sometimes be de- 
tected. 

Convalescence may commence at any stage. In a very large pro- 
portion of cases, the patient begins to recover before there has been 
any obvious effusion of fluid; pain in the side gradually ceases, febrile 
symptoms (if there be any) subside, and friction slowly vanishes. In 
other cases convalescence does not commence until after fluid has accu- 
mulated, and more or less of the lung has been compressed. Here, 
again, convalescence is indicated by subsidence of fever and general 
improvement in the condition of the patient's bodily functions ; his 
breathing becomes more natural, and his appetite returns. At the 
same time the effused fluid becomes gradually absorbed, the pleural 
surfaces come again into contact and consequently pain may temporarily 
return and friction become re-established. Indeed, friction usually is 
a much more marked phenomenon of convalescence than it is of the 
early stage of the disease. It may happen that, with the disappear- 
ance of the fluid, the lung enlarges, and healthy respiratory sounds are 
speedily restored ; but, even in favorable cases, it is usually a long 
time (it may be months) before friction wholly disappears, and even 
longer before resonance and respiratory sounds return to the basal 
portion of the affected side of the chest. In less favorable cases, the 
lung is restored in part only, or remains permanently collapsed. Then 
all those changes in the form of the side and the arrangement of the 
internal organs, which have been already described, slowly ensue. 
But even here some improvement may be hoped for in the course of 
years. The patient, however, usually remains weakly and short of 
breath. 

The cause of death in simple pleurisy is commonly asphyxia due 
to the pressure of the accumulated fluid ; the patient may, however, die 
from syncope or asthenia, and in either case death is apt to take place 
suddenly. 

The supervention of suppuration — the development of empyema — 
is often insidious and unattended with either the aggravation of old 
symptoms or the occurrence of new ones. The simple long persistence 

26 



402 



DISEASES OF THE RESPIRATORY ORGANS. 



of copious effusion affords presumptive evidence of suppuration. Sup- 
puration is generally also indicated when there has been, from the begin- 
ning of the attack, much fever, and rapid filling of the side with fluid, 
and especially when, in the course of a case hitherto of only moderate 
severity, rigors occur, and fever, becoming greatly augmented, con- 
tinues augmented. The local indications of empyema are not neces- 
sarily more pronounced than the general symptoms. In addition to 
those of distension from mere accumulation, we sometimes observe 
general or partial oedema of the integuments on the affected side, 
sometimes distinct bulging of the intercostal spaces, sometimes un- 
natural distinctness of the superficial veins, and sometimes a circum- 
scribed fluctuating swelling, superficial to the ribs, due to the escape 
of matter from the pleural cavity through an intercostal space into the 
soft tissues beneath the integuments. We have pointed out that an 
empyema may burrow in almost any direction and discharge itself at 
almost any surface ; the most important practical terminations of this 
kind, however, are by perforation of the lung and by perforation of the 
thoracic parietes. In the former case the patient suddenly expectorates 
a large quantity of pus, and may continue henceforth to discharge pus, 
either continuously, in comparatively small quantities, or at irregular 
intervals profusely. In some cases of circumscribed empyema, such a 
discharge may be the first indication that suppuration has taken place. 
In the case of discharge through the thoracic parietes, the abscess first 
points, and then opens either spontaneously or by operation, and as in 
the former case pus, in more or less abundance, escapes, and probably 
continues to escape. In this case, also, the appearance of a superficial 
abscess is sometimes the first clear indication that there has been a cir- 
cumscribed empyema. But it must not be forgotten that a superficial 
abscess often communicates, by a comparatively long and tortuous 
passage, with the internal abscess which gave it origin ; and that hence 
(especially in the case of circumscribed empyema), it may he impossible 
to trace the superficial abscess back to its source, and hence to make 
sure of its empyematous origin. Thus a circumscribed empyema at 
the base of the pleura may in its progress be readily and pardonably 
mistaken for a perinephritic or a lumbar abscess. The progress of a 
discharging empyema is apt to be very chronic, especially if the origi- 
nal cavity were large. It may continue to discharge (the discharge 
often becoming fetid) for weeks, months or years; during which time, 
in dependence partly on the copiousness of the discharge, the patient 
becomes emaciated, and presents the ordinary symptoms of hectic 
fever. In many such cases, fortunately, recovery, more or less com- 
plete, takes place after a time; this event is, on the whole, more 
frequent when the empyema opens through the lung than when it dis- 
charges externally — a circumstance which seems to depend in some 
degree on the much greater tendency that there is in the latter case 
than in the former to the decomposition of the purulent contents. In 
many cases, on the other hand, the patient slowly sinks and at length 
dies, worn out and exhausted, or he is carried off by sudden intrapleu- 
ral haemorrhage, or asphyxia. 

It necessarily often happens that the communication of an empyema 



PLEURISY. 



403 



with the bronchial tubes, or directly with the external atmosphere, 
permits of the entrance of air into the pleural sac, and that hence pneu- 
mothorax is established. The supervention of this condition may be 
ordinarily recognized by the presence of augmented resonance (generally 
of heightened pitch) over the air-containing portion of the cavity, of 
the splashing sound caused by succussion, of cavernous resonance, and 
probably of distinct metallic tinkling. 

In the foregoing account we have mainly discussed the symptoms of 
simple unilateral idiopathic pleurisy; it may be added that the symp- 
toms of the complicated disease are essentially the same, but that they 
are interwoven with those of the complicating disorder, and are some- 
times masked by them ; and further that both pleurae are occasionally 
implicated, with corresponding aggravation of symptoms. We may 
also add that pleuritic patients, during the period of effusion, usually 
lie on or towards the affected side ; and also that they much more fre- 
quently suffer from cough than might perhaps be gathered from the 
remarks we have made. The cough, however, is no necessary part of 
the disease, and is often due to the presence of associated pneumonia or 
bronchitis. 

Treatment. — The treatment of ordinary cases of pleurisy is not usually 
a matter for anxiety. In mild cases of so-called dry pleurisy the ap- 
plication of a mustard plaster or other counter-irritant, the binding of 
the chest with a broad flannel roller to restrain its movements, and the 
use of opiates in small doses will probably be sufficient. 

In severer cases, in which there is manifest fever and increasing 
effusion, it is often beneficial to apply (according to circumstances) from 
half a dozen to a dozen leeches to the surface of the chest, to follow up 
their application by poultices or by flannels wrung out in hot water, 
and then perhaps after a time by counter-irritants. In these cases, 
even more than in the former, opiates are generally of extreme value, 
if only to aid in the alleviation of pain and in the relief of distress. 
Soda-water, or some other febrifuge medicine, may also be employed. 

If the effusion still increase, and especially if the patient begin to 
suffer from shortness of breath, the arrest of the effusion and the re- 
moval of that which has already accumulated, become the chief indica- 
tions for treatment. For these purposes diuretics, diaphoretics, and 
purgatives have each been strongly advocated, and among drugs mer- 
cury, antimony, digitalis, and iodide of potassium. We believe that 
all these agents are practically useless for the purposes here indicated, 
and that, if we are to trust in drugs at all, they should be those which, 
by tending to improve the general health of the system, tend indirectly 
to promote healthy action at the seat of disease : we mean tonics, espe- 
cially iron and quinine. Counter-irritants, and especially repeated 
small blisters, seem to act sometimes in the promotion of absorption. 
The only other means at our disposal for the removal of fluid, and this 
is in many respects by far the best, is the operation of paracentesis. 
This operation was formerly greatly dreaded and rarely performed ex- 
cept in cases of empyema already pointing. It is in great measure due 
to Trousseau that, during the last thirty years, paracentesis has come 
to be recognized as a safe and efficacious procedure in cases of excessive 



404 



DISEASES OF THE RESPIRATORY ORGANS. 



accumulation of simple serum. More recently, especially since the 
introduction of suction instruments, and through the able advocacy of 
Dr. Bowditch, the use of the operation has been still more widely 
extended. The objects to be attained by paracentesis are: first, the 
removal of pressure from the lung so as to permit of its redistension ; 
second, the prevention of death from suffocation ; and, third, the re- 
moval of purulent fluid. It is also generally believed, and perhaps cor- 
rectly, that the removal of a certain proportion of fluid from a distended 
cavity promotes the absorption of the rest. 

With the first of the above objects the fluid should be removed early 
in the course of effusion, inasmuch as the longer the lung has been 
compressed and the more firmly it is bound down by adhesions the 
less likely is restoration to take place. With the second of these 
objects the pleura should be punctured either when the patient suffers 
from obvious difficulty of breathing, or when, even if dyspnoea seems 
absent, the cavity is greatly distended. In reference to the removal 
of circumscribed accumulations of pus, it is often best to perform in 
the first instance an exploratory operation. In all these cases a fine 
trocar and canula should be employed ; the instrument should be 
plunged into the chest at a suitable point, generally, as recommended 
by Dr. Bowditch, an intercostal space directly below the angle of the 
scapula and above the lower limit of the opposite healthy lung ; and 
the fluid should be removed either by the aspirator, or by a tube 
guarded by a valvular fold of goldbeater's skin, so as to prevent the 
admission of air. The admission of air, however, though an accident 
to be avoided as involving additional risk, has in a considerable num- 
ber of cases had no ill effect ; further, it is not generally advisable to 
attempt the removal of the whole of the fluid at one time. If pus be 
present it may be removed by periodical aspirations, or its free dis- 
charge may be maintained through a permanent opening. For the 
different methods by which at the same time a free escape of pus may 
be allowed and the entrance of air prevented, we must refer to surgical 
works. It is sufficient to say here that, so long as the discharge re- 
mains free from fetor, the entrance of air must be carefully guarded 
against; when, however, the discharge becomes fetid, little is to be 
gained by further exclusion of air. It then becomes important to wash 
out the cavity daily either with pure water or with water medicated 
with quinine, nitric acid, chlorinated soda, or carbolic acid. The 
operation of paracentesis with a very fine trocar and canula, if air be 
excluded, is perfectly harmless. And it is indeed of little importance 
if in attempting it we wound the lung, or the kidney, or other neigh- 
boring organs. 

In the treatment of chronic pleurisy, or empyema, and during the 
whole period of convalescence, the importance of tonics, good diet, and 
change of air cannot be overestimated. 



CIRRHOSIS. 



405 



CIRRHOSIS. (Chronic Pneumonia. Fibroid Phthisis.) 

Definition. — A distinction is not unfrequently made between cir- 
rhosis and chronic inflammation of the lungs. It is difficult, however, 
to appreciate in what the difference between them consists, and we 
prefer therefore to regard the two conditions as identical. We mean 
by these expressions induration of the lung-tissue by the development 
of nucleated fibroid tissue either around the bronchial tubes or in the 
interlobular septa, or in the walls of the air-cells, or in all these situa- 
tions at once, and by the consequent gradual effaeement of the air- 
cells themselves. 

Causation. — There is reason to believe that cirrhosis is an occasional 
result of ordinary acute pneumonia; it is far more frequently, however, 
a sequel of catarrhal or lobular pneumonia and of chronic pleurisy with 
effusion. A by no means unfrequent cause is the continued inhalation 
of solid particles, such as those of coal-dust, millstone grit, copper ore, 
flax-dust, and the like, by those whose occupations expose them to the 
dangers of such inhalations. It is certain that it occasionally ensues 
on simple chronic bronchitis and on the retrogression of both gray and 
caseous tubercular deposits. The question how far, in some cases, it is 
to be regarded as the result of a constitutional taint, has been often 
raised. There is no doubt that we occasionally meet with a similar 
condition simultaneously involving several organs, more especially the 
lungs, liver, and kidneys, a fact which is certainly entitled to some 
weight on the affirmative side of the question. But, on the other 
hand, it must be remarked that hepatic cirrhosis is traceable, in the 
great majority of cases, to the influence of alcoholic irritation of the 
matrix of the liver, and that pulmonary cirrhosis (independent of tuber- 
culosis) is usually exclusively limited to one or other lung, — facts which 
are at least as weighty on the opposite side. 

Morbid Anatomy. — Cirrhosis of the lung essentially consists in the 
gradual invasion of the solid tissues of the organ by a nucleated fibroid 
growth. This, on the one hand, surrounds and involves the bronchial 
tubes (especially the smaller ones) and the vessels which accompany 
them ; on the other hand, invests the lung itself (which is then usually 
strongly adherent to the parietes) and separates its lobes from one an- 
other ; and from both sides is prolonged into the interlobular septa, so 
as to divide the lung-tissue by bands of fibroid tissue of different 
degrees of density, thickness, and visibility, into a series of polygonal 
islets. With the further progress of the disease, the same kind of 
thickening takes place irregularly in the walls of the air-cells, so that 
before long the cut surface presents a coarse retiform. arrangement of 
dense fibroid tissue ; and this, gradually increasing, finally renders the 
whole organ, or portions of it, uniformly dense, hard, and airless. It 
must be observed that, although in cirrhosis there are usually both 
induration of the tissues around the bronchial tubes and dense ad- 
hesions between the opposed pleural surfaces, it often happens that the 
most obvious, if not the primary, change is that which pervades the 



406 



DISEASES OF THE RESPIRATORY ORGANS. 



ultimate tissue of the lungs. It need scarcely be said that this is 
necessarily the most important. 

Accompanying the interstitial growth of fibroid tissue, there is 
usually a more or less abundant deposit of black pigment. This is 
natural in the lungs of persons advanced in age; but in cirrhosis it is 
often, if not always, excessive. The pigment is deposited in the 
thickened walls of the air-cells and especially in the connective tissue 
which surrounds the bronchial tubes and vessels, and that which sepa- 
rates lobules from one another. It is always also abundant in the 
bronchial glands. The pigment is deposited in irregular patches, but 
may often be found to be distinctly contained in the connective-tissue 
corpuscles, and to take the course of the lymphatic vessels. Indeed, 
there is good reason to believe that it is to a large extent carbonaceous 
matter of extraneous origin, which has been inhaled into the lungs, 
has been absorbed by the mucous surfaces of the respiratory tract, and 
has then become deposited in the tissues and taken up by the lym- 
phatics. The presence of such pigment usually gives a peculiar mot- 
tled aspect to the sectional surface of the cirrhosed lung ; but if in 
great abundance, it renders the tissues uniformly and intensely black. 

The ultimate effect of cirrhosis of the lung, like that of the same 
condition in the liver, although it may perhaps under some circum- 
stances cause temporary enlargement, is to produce gradual contraction 
and diminution of the organ. The progress of the disease is further 
always complicated with dilatation and other changes in the bronchial 
tubes, and not unfrequently with equivalent affections of the air-cells 
themselves. The larger tubes are generally more or less considerably 
dilated, the fibroid and muscular bands which mark their mucous sur- j 
face with longitudinal and transverse ridges become hypertrophied and 
produce a coarsely reticulated appearance, and the mucous surface 
itself is probably congested and thickened. The chief changes, how- 
ever, occur in connection with the smaller tubes, which in some cases J 
are dilated into bulb-ended channels; sometimes terminate in round or 
subglobular cystiform expansions, from the size of a cherry to that of 
a small pea ; sometimes open (several of them in common) into cysts or 
cavities of large size and irregular form ; sometimes are continued into 
recently-formed and progressing cavities, which, when small, may easily 
be recognized as originating in the ulcerative destruction of the walls 
of the smaller tubes and air-passages. The mode of origin of dilated j 
tubes in this and other pathological conditions will be considered here- 
after. It will be sufficient to say here that, in many cases, so-called 
" dilated tubes 7 ' are merely tubes in communication with cavities whose 
walls have undergone cicatrization; that there is (as might be sup- 
posed) a strong tendency for the adventitious fibroid growth of cirrhosis 
to undergo liquefaction under the influence of inflammatory processes 
commencing at the bronchial surface; and that not only the formation 
of vomica?, but probably also that of many of the dilated tubes, are 
referable to such liquefaction. There is no doubt that ordinarily the 
air-cells, in cases of cirrhosis, gradually become obliterated, retaining | 
sometimes in their diminished cavities disintegrating epithelial and 
other cells ; but not unfrequently more or less emphysema is developed 



CIRRHOSIS. 



407 



at the same time. When cirrhosis is limited to some comparatively 
small tract of lung, emphysema is common in the tissue which imme- 
diately bounds the indurated patch. Occasionally, also, the formation 
of a dense fibrous reticulum throughout the lung is to a greater or less 
extent associated with the dilatation and breaking down of the thick- 
ened walls of the air-cells, so that the cut surface of the lung becomes 
not altogether unlike that of a coarse sponge. We have an impression 
that the condition last described may ensue on the retrogression of a 
crop of miliary tubercles. 

Cirrhotic lungs present very great variety of appearance and charac- 
ter; at the same time it is easy to see that, however much they may 
differ from one another in the stage of the disease which they have 
reached, in the amount of pigment which is present in them, in the 
condition of their bronchial tubes, and in the tendency to the forma- 
tion of vomicae, they are all linked together by the community of their 
origin in simple fibroid overgrowth. The following are some of the 
varieties of cirrhosis which have been described and named : Red 
induration. — This name is given to an early or slight condition of the 
disease, in which the lung is of large size, red, fleshy, and, although 
denser than natural and infiltrated to some extent with adventitious 
growth, still contains air. Brown induration. — This name has been 
employed to designate a condition of lung in which the capillaries are 
dilated and thickened, and in which the color of the organ has a 
yellowish-brown tint, and the fluid exuding on pressure is similarly 
colored, in consequence of the presence in the tissues of the lung of the 
coloring matter of the blood in the form of pigment-granules. Brown 
induration is especially an accompaniment of heart disease. Gray 
induration is the name which is sometimes applied to the condition of 
the lung in advanced cirrhosis, when the organ is extensively infil- 
trated with fibroid matter and presents in consequence a general grayish 
tint and more or less translucent aspect. Black induration is some- 
times used as the designation of that form of cirrhosis in which the 
cirrhotic tissue is largely infiltrated with black pigment, and of which 
the most striking examples are furnished by the lungs of persons work- 
ing in mines or otherwise exposed to the inhalation of soot or other 
carbonaceous matters. It may be added that the pulmonary affections 
which are so frequently the causes of death amongst those who are 
engaged in certain avocations, as, for example, amongst miners, colliers, 
flax-dressers, millstone grinders, and the like, and which are commonly 
known as the phthisis of those who are thus respectively engaged, are 
mostly, as has been already indicated, of the nature of cirrhosis. They 
originate in the bronchitis which is caused and maintained by the con- 
stant inhalation of solid particles. Of these particles a greater or less 
abundance is taken up into the solid tissue of the lungs, and remains 
there permanently; and fibroid infiltration slowly supervenes. It 
appears from Dr. Greenhow's investigations that the nature of the 
dust inhaled does not exert any specific influence over the morbid 
changes which ensue. The nature of the imbedded particles can gen- 
erally, however, be pretty readily recognized with the aid either of the 
microscope or of chemical reagents. 



408 



DISEASES OF THE RESPIRATORY ORGANS. 



Symptoms. — The symptoms of cirrhosis of the lungs, apart from 
those of the numerous conditions which complicate it, and from those 
of the morbid conditions out of which it may have arisen, scarcely 
admit of description or recognition. The disease is one the progress 
of which is exceedingly chronic, and may be prolonged for five, ten, or 
even fifteen years. 

It is easy to see that, if any large extent of lung-tissue be involved, 
the patient must suffer from progressive breathlessness ; that from the 
obstruction which the indurated and contracted lung-tissue opposes to 
the pulmonic circulation, hypertrophy and dilatation of the right side 
of the heart must ensue, to be followed sooner or later by general ana- 
sarca; that there must gradually supervene impairment of nutrition, 
failure of the general powers of the body, weakness and emaciation ; 
that the pulmonary changes must result in impairment of thoracic 
movement with retraction of the thoracic parietes, more or less obvious 
dulness on percussion, and either suppression of the respiratory sounds, 
or tubular breathing, or (if there be secretion into the tubes) the various 
unnatural sounds which secretion is competent to induce. Generally, 
moreover, there are present (at all events at some stage or other of the 
affection) more or less bronchitis with secretion, more or less dilatation 
of the tubes or air-cells, more or less breaking down of tissue, with 
the formation of vomicae, and more or less distinct inflammatory action ; 
and the symptoms of these conditions must be added in order to have 
a true picture of the symptomatic phenomena of cirrhosis of the lungs. 

Briefly, then, it may be stated that a patient with cirrhosis presents 
the following symptoms variously combined : He has more or less 
obvious dyspnoea, especially on exertion, which gradually increases 
upon him, and is generally aggravated during the winter months, or 
by the occurrence of catarrh or pulmonary inflammation. Pallor and 
lividity of surface, with congestion of the nose, fingers, and toes, often 
supervene sooner or later. Cough is almost always present in a greater 
or less degree; and in some cases is very severe; it may, however, be 
wholly absent, especially during warm weather. It may or may not 
be attended with expectoration ; but expectoration is often profuse, 
especially when the cirrhosis is complicated with dilated tubes or 
vomicae, and generally mucopurulent or purulent. Under the same 
circumstances it is liable to be extremely fetid, and, in the case of 
colliers and others, almost black from the presence of pigment-particles. 
Haemoptysis is not unfrequent. In many cases the sputa are merely 
streaked with blood as in ordinary chronic bronchitis ; in some cases, 
however, more or less profuse haemorrhage occurs from time to time. 
This is sometimes due to perforation of bloodvessels in the course of 
destructive changes, sometimes to intense hyperemia (probably of in- 
flammatory origin) of the lining membrane of the dilated tubes. The 
auscultatory and percussive phenomena will be considerably modified 
according as dilated tubes or cavities are absent or present, and accord- 
ing as these are full or empty of fluid. The pulse may at first present 
little departure from the normal, but as the disease progresses it tends 
to become rapid and weak, and sometimes irregular; and at the same 
time, as has been pointed out, general anasarca may ensue. Elevation 



TUBERCULAR DISEASE. 



409 



of temperature and other febrile symptoms are very variable in their 
occurrence. Not unfrequently, at certain periods of the affection there 
is a total absence of them; but much more commonly the patient pre- 
sents more or less of the usual symptoms of hectic fever, — some degree 
of elevation of temperature, which is, however, liable to fluctuations ; 
perspirations; loss of appetite; sometimes vomiting and diarrhoea; 
and gradually increasing emaciation and debility. The local and 
general symptoms and the history of cirrhosis not unfrequently closely 
resemble those of retraction of the lung after simple pleurisy, or those 
of chronic bronchitis with emphysema, or those of phthisis. 

Treatment. — Our principal aims in the treatment of cirrhosis should 
be, by attention to hygiene and to diet, to arrest the progress of the 
morbid process, to prevent the supervention of complications, and to 
maintain the bodily strength. For these purposes change of scene, 
removal to a mild but equable and bracing air in the summer, to a 
warm southern climate in the winter, the avoidance of night air, of 
exposure to sudden chills, of overfatigue and the like, the use of good, 
wholesome, and abundant diet, with a moderate amount of stimulants, 
and of quinine, iron, cod-liver oil, or other tonics, are of vital impor- 
tance. When the cirrhosis is due to occupation, the patient should 
give it up and follow some more healthy pursuit. But, in addition, 
symptoms as they arise will necessarily call for treatment; cough and 
expectoration may demand opiates and expectorants, hsemoptysis astrin- 
gents, shortness of breath, diffusible stimulants, diarrhoea medicines 
which check the alvine flux. It is needless, however, to pursue the 
list of possible complications, and to indicate the various methods by 
which they may severally be relieved. 



TUBERCLE. (Laryngeal and Pulmonary Phthisis. 
Tubercular Pleurisy.) 

Causation. — The aetiology of tuberculosis is a subject of the highest 
interest, and at the same time one of extreme difficulty. There are 
few affections in which the influence of hereditary taint is so strongly 
shown. It is a w r ell-established fact that children of tubercular parents 
are pre-eminently liable to tubercular affections, and not only so, but 
that, if one parent be tubercular, the children who most resemble that 
parent in conformation are most prone to be affected ; and, further, 
that parents, themselves seemingly healthy, or at all events free from 
tubercle, not unfrequently beget a family of children who die one after 
the other of pulmonary phthisis. In the case last referred to the tuber- 
cular tendency of the children may be due either to the transmission of 
a taint (latent quoad the parent), or to the fact that one or other parent 
is scrofulous or syphilitic, or in some other way impaired in health. 
But tuberculosis does not occur among those only who inherit a ten- 
dency to it. Climate has certainly some influence in its production ; 



410 



DISEASES OF THE RESPIRATORY ORGANS. 



thus it is much more frequent in temperate climates than it is either in 
those which are very cold or in those which are very hot; and Dr. 
Buchanan's and Dr. Bowditch's researches seem to prove that in tem- 
perate climates it prevails far more extensively in low, damp situations 
than it does in elevated and dry localities. There is no doubt that 
conditions which produce deterioration of the general health tend ulti- 
mately to induce tuberculosis : among these may be enumerated inade- 
quate nourishment, excessive work with insufficient rest, and want of 
fresh air. Hygienic defects of this kind are specially injurious to the 
young. Other causes of tuberculosis are occupations which necessitate 
the inhalation of solid irritating particles (for there is no doubt that 
tuberculosis, as well as cirrhosis, and not un frequently both in combi- 
nation, are thus produced), and the cachexia? which follow or attend 
upon various diseases, especially perhaps enteric fever, measles, hoop- 
ing-cough, syphilis, and diabetes mellitus. No age is free from 
liability to tuberculosis; it is extremely common in young children, 
but, putting these on one side, the age of greatest liability is from 
twenty to thirty or thirty-five. The influence of sex is uncertain. 

Morbid Anatomy. — 1. Laryngeal tubercle always manifests itself in 
the form of minute gray granulations, which may very readily be over- 
looked, but which, nevertheless, present in their typical completeness 
all the microscopical and other characteristics of gray tubercles. They 
are situated in the substance of the mucous membrane, and tend after 
a time to form small round shallow ulcers, which by their coalescence 
constitute sinuous but rarely extensive tracts of ulceration. It is very 
common indeed in the course of pulmonary phthisis for the larynx to 
become implicated ; but to what extent this implication is due to actual 
tuberculosis of the larynx is a matter of considerable doubt. The 
mucous membrane becomes congested, oedematous, and thickened, 
excoriations appear, and sooner or later extend deeply, exposing the 
cartilages, and causing their erosion. These deep ulcers are most com- 
monly situated towards the posterior extremities of the vocal cords, 
and involve the anterior processes of the arytenoid cartilages. All the 
cartilages are, however, liable to become thus affected. 

The trachea and bronchi are subject to the same pathological changes 
as the larynx : their mucous membrane becomes congested and thick- 
ened, excoriations manifest themselves with or without the pre-existence 
of miliary tubercles, and occasionally the cartilaginous rings become 
exposed and eroded, and even detached and expectorated. 

2. Pulmonary Tubercle. — There is no doubt that those who deny the 
identity between gray and yellow tubercles will, equally with those 
who maintain the opposite thesis, admit that the two varieties often 
coexist in the same individual ; and, on the other hand, there is no 
doubt that those who believe in their identity will, equally with their 
opponents, acknowledge that cases of tuberculosis are not unfrequently 
met with which are characterized by the exclusive presence of one or 
other form. It will be convenient, therefore, while acknowledging 
their tendency to pass the one into the other, to describe them inde- 
pendently, as we not unfrequently meet with them in typical cases. 

Gray tubercles vary in bulk from mere points up to the size of a 



TUBERCULAR DISEASE. 



411 



small pea, but do not usually exceed that of a pin's head ; they are 
gray, somewhat hard, and slightly translucent; they are sometimes 
sparsely scattered, sometimes very closely set, in some cases distributed 
with tolerable uniformity, in others forming scattered groups or clus- 
ters of various sizes. In the last case those towards the central part of 
a group coalesce, to a greater or less extent, and form tracts of tuber- 
cular growth individually as large as a marble or a walnut. The 
development of gray tubercles is occasionally limited to one lung; 
more frequently it comprises both, and may then involve them equally 
or unequally. They are in some cases distributed throughout the 
whole organ, in some limited to certain regions, generally the apex ; 
and for the most part, even when universally distributed, they are 
most numerous and most advanced in the upper part of the lung. The 
growth of miliary tubercles is always, in a greater or less degree, as- 
sociated with other morbid conditions of the lung: these are especially 
congestion and oedema of the pulmonary tissue, or consolidation of the 
intermediate tracts of lung, or bronchial catarrh mainly implicating 
the minuter tubules. As regards the consolidation, it must be observed 
that this may be of the nature of ordinary pneumonia, with impaction 
of the air-cells with corpuscular elements, or of the nature of cirrhosis 
with fibroid thickening of the walls of the air-cells and of the other 
connective tissues of the lung. A later change is the breaking-down 
of the consolidated portions of lung and the formation of vomicae. 
Such cavities usually commence at the apex, and may be limited to 
that part. They may vary from the size of a pea up to that of an 
orange or beyond, and present every variety of form. They are usually 
surrounded with a greater or less thickness of indurated tissue, and 
often present abrupt w r ell -defined margins. 

For the most part, miliary tubercles are developed with great rapid- 
ity, and tend to a rapidly fatal issue. There is no doubt, however, that 
occasionally their progress is arrested, and the patient recovers, but 
with more or less permanent damage to the tissue of the lung. When 
this happens in respect of discrete tubercles, the organ becomes seamed 
throughout with minute patches of cicatricial tissue, the fibres of which 
have something of a stellate arrangement, and within the limits of 
which the lung-tissue presents, from the presence of concurrent em- 
physema, a coarsely spongy character ; and occasionally in the centre of 
the scars minute fibroid knots or concretions may be recognized. When 
the affection becomes arrested after groups of tubercles have become 
consolidated by the intervention of inflammatory overgrowth, more or 
less extensive tracts of tissue, studded probably with cretaceous or 
caseous masses and with black pigment, assume a cirrhotic character, 
and become contracted, while usually more or less emphysema becomes 
developed in their immediate neighborhood. Further, when cavities 
have formed, they either contract and become lined w r ith a definite 
smooth membrane, continuous with that of the bronchial tubes, or pos- 
sibly, in rare cases, become obliterated. 

Yellow tubercles in process of development present an opaque, yel- 
lowish-white, slightly granular character. They are peculiarly dry and 
friable, furnishing no juice, but readily yielding, on being scraped or 



412 



DISEASES OF THE RESPIRATORY ORGANS. 



squeezed, a pulpy detritus. They are usually of larger size than gray 
tubercles, and present for the most part a well-defined outline and a 
more or less irregular form. They evidently comprise groups of air- 
cells or of lobules, and are hence polygonal when cut across ; but when 
divided in the direction of the bronchial tubes, are found to involve 
the minuter branches of these and to be arranged upon them in a tabu- 
lated or foliaceous manner. In their early stage a cross-section will 
probably have the size of a split tare or pea ; they soon, however, partly 
by individual growth, partly by coalescence, assume larger dimensions. 
Occasionally, as the result of such coalescence, large tracts of lung- 
tissue, sometimes the whole of a lobe, become uniformly infiltrated — a 
condition to which, in the nomenclature of the College of Physicians, 
the name of " chronic pneumonic phthisis" has been given. 

Yellow, like gray tubercles, usually commence at the apex of a lung, 
sometimes at the apex of the lower lobe, and spread thence gradually 
downwards. They are usually, too, more advanced at the apex than 
elsewhere. It must not, however, be forgotten that they may originate 
and attain their most advanced stage in any part of the lung. The 
tendency of yellow tubercles to undergo liquefaction is far more marked 
than is that of gray tubercles; so that, although in rare cases a lung 
may become very largely involved without breaking down, in the great 
majority of cases softening takes place both early and extensively. 
In one case of rapid phthisis which came under our notice, destructive 
softening must have been almost coetaneous with the development of 
the tubercles, for though both lungs were thickly studded with cheesy 
masses, there was scarcely one of them which was not in great meas- 
ure or wholly converted into a flocculent-walled cavity. The lungs, 
indeed, were lighter than natural, and appeared at the first glance to 
have large air-containing bulla? thickly disseminated throughout their 
substance. The vomica? of this form of phthisis usually originate in 
the upper parts of the lungs, and there attain their chief development. 
They commence with the liquefaction of those portions of the masses 
which immediately bound the bronchial passages and smaller tubules; 
so that, in the first instance, though roundish when cut transversely, 
they present a dendritic form when the incision takes the course of 
these channels. A cavity once commenced increases more or less 
rapidly in size, and ere long, by coalescence with neighboring cavities, 
may assume gigantic proportions. It may indeed occupy the whole of 
a lobe. Large cavities are usually more or less anfractuous in form, 
and often crossed by bands of condensed tissue, comprising vessels 
(mostly impervious) of considerable size. Cavities in process of forma- 
tion present more or less ragged parietes ; but when they have ceased 
(as they often do cease) to enlarge, their surfaces become smooth, and 
even polished, and the tissues round them more or less indurated. Yel- 
low tubercle not unfrequently undergoes retrogressive changes. These 
consist in its gradual conversion, first, into a mortary, and lastly, into 
a calcareous inert mass, encapsuled by a dense fibroid envelope. The 
contraction of cavities, the calcareous conversion of tubercular masses, 
and the induration of the tissues around, are always attended with dim- 



TUBERCULAR DISEASE. 



413 



inution in the bulk of the affected portions of lung, and compensatory 
expansion of the neighboring healthier tissues. 

It must be added that, in both forms of tuberculosis, it happens 
sometimes that gangrene takes place ; sometimes that profuse haemor- 
rhage occurs either from intensely congested surfaces or from the per- 
foration of an artery or vein, which perforation is occasionally preceded 
by the formation of an aneurismal dilatation ; and that sometimes the 
tubercular vomica, like any other abscess within the chest, opens into 
the pleura, or through the outer thoracic walls, or perforates the dia- 
phragm. 

3. Pleural tubercle differs in no important respect from tubercle of 
other serous membranes. It almost invariably appears here in the 
form of minute grayish spots, variously arranged, sometimes occupying 
the serous membrane itself, sometimes apparently imbedded in the 
substance of recently-formed false membranes. These bodies are some- 
times scattered over the whole surface, sometimes limited to certain 
spots; and are generally, even when widely spread, most thickly con- 
gregated in certain regions where it may be presumed they originated. 
They are often very numerous between the lobes and upon the dia- 
phragmatic surface. When very abundant they touch one another, 
or coalesce so as to form extensive tracts of tubercular infiltration. 
When this takes place the opposed pleural surfaces are usually adherent, 
and the tubercular lamina? appear to occupy the substance of the inter- 
vening false membrane. As the tubercles increase in size and run to- 
gether they assume an opaque buff color and become friable, resembling, 
indeed, in their look and consistence, cheesy masses in the lungs. Pleural 
tubercle is, in the great majority of cases, associated with tubercle of 
other organs ; occasionally, however, it is primary in the pleurae, and 
may even be limited to one. It is very commonly associated with 
tubercle of other serous membranes ; it is also, as might be supposed, 
usually coincident with some amount of miliary formation in the lungs 
themselves. It is nevertheless a fact that tuberculosis of the pleura is 
by no means a frequent complication of pulmonary phthisis, notwith- 
standing that pleuritic inflammation is an invariable attendant on that 
affection. Tubercle of the pleura is not necessarily accompanied with 
inflammation of that membrane ; in most cases, however, sooner or later, 
and sometimes from the very commencement, inflammation takes place, 
and the usual phenomena of pleurisy become combined with those of 
tuberculosis ; false membrane is formed, effusion takes place, suppura- 
tion perhaps ensues, and any one or all of the various events which 
have been already fully considered under the head of pleurisy are apt 
to supervene. 

It would be out of place here to enter at any length upon the asso- 
ciated morbid anatomy of tubercular affections of the respiratory 
organs, which plays, however, so important a part in the progress and 
symptoms of ordinary cases of pulmonary phthisis. It will be sufficient 
to draw attention to the fact that tubercles are rarely limited to these 
organs, and that their simultaneous development in other organs may 
induce consequences of much more urgent gravity than those referable 
to the laryngeal, pulmonary, or pleural affection. Among the more 



414 



DISEASES OF THE RESPIRATORY ORGANS. 



important of such complications of pulmonary phthisis are inflamma- 
tion of the lungs and pleurae, tubercular meningitis, tubercular perito- 
nitis, and tubercular ulceration of the intestine, to which may be added 
the fatty and lardaceous degenerations of various organs. 

Symptoms and Progress. — So much attention has been devoted to 
the symptomatology of pulmonary phthisis, so much has been written 
on this subject, and so elaborate are the details with which we have 
been furnished, that it seems at first sight an almost hopeless task to 
endeavor to compress our description of the symptoms of the disease 
within reasonable limits. When, however, we bear in mind that, in 
most of the elaborate accounts to which we refer, the symptoms of pul- 
monary phthisis are made also to include the symptoms due to tuber- 
culosis of all other organs, those referable to the many complications 
which are apt to supervene in the course of phthisis, and besides these 
the symptoms of the various forms of ill-health which so often precede 
phthisis, it will be seen that the symptomatology of the pulmonary 
affection has been overlaid with an abundance of matter which, how- 
ever important, does not immediately concern us now. The following 
description will be almost exclusively limited to the symptoms which 
are referable to the affections of the respiratory organs themselves. 

In a large number of cases the invasion of pulmonary phthisis is 
remarkably insidious. A patient who has previously, it may be, en- 
joyed robust health, becomes slowly and without obvious cause weak 
and thin, suffering probably at the same time from slight remittent 
febrile symptoms ; or he may, possibly after exposure to the causes of 
catarrh, become the subject of dry irritating cough which he cannot 
shake off, and which, ere long, becomes attended with loss of flesh and 
strength ; or he may suffer in the first instance from slight symptoms 
of laryngeal inflammation, which slowly increase in severity; or he 
may, without previous warning, have a sudden and profuse attack of 
haemoptysis, on the subsidence of which some of the various symptoms 
above considered supervene ; or a patient, subsequent to an attack of 
fever, or of pneumonia, or in the course of some wasting disease, may 
be attacked with cough, and the symptoms of phthisis may gradually 
replace those of the primary malady. The frequent occurrence of 
gradual deterioration of health, without the presence of any specific 
symptoms of disease, prior to the obvious development of pulmonary 
phthisis, has induced many physicians to believe in the existence of a 
stage of phthisis antecedent to that of tubercular deposition — a belief 
based, however, on utterly insufficient data. 

But in whatever way phthisis first manifests itself, the symptoms 
of the fully-developed disease become ere long established. These 
consist mainly in cough, attended with more or less abundant muco- 
purulent expectoration, and occasional or frequent haemoptysis ; hectic 
fever, marked by more or less regularly periodical febrile exacerbations, 
profuse perspirations, especially at night-time, rapid emaciation, and 
loss of strength ; and the local evidences, on percussion and ausculta- 
tion, of progressive involvement and destruction of lung-tissue. 

We proceed to discuss the various symptomatic phenomena of 
phthisis seriatim. In a certain number of cases the symptoms of which 



TUBERCULAR DISEASE. 



415 



the patient first complains are referred to the larynx ; and it may be 
that throughout the whole course of the affection the laryngeal symp- 
toms continue chiefly distressing to him. These symptoms differ 
scarcely at all from those of ordinary chronic laryngitis except in their 
obstinacy, in their progressive character, and in the gradual superven- 
tion of emaciation and loss of strength, and of indications of advancing 
pulmonary disease. In a still larger number of cases, and indeed in a 
very large proportion of the entire number of cases of phthisis, laryn- 
geal symptoms of a more or less severe character come on sooner or 
later in the course of the pulmonary disease. These are sometimes 
simply irritative or catarrhal, and subside ; but more frequently they 
resemble in all respects, inclusive of their causation and progress, those 
of the earlier laryngeal affection. It is a question which can scarcely 
be said to be even now clearly decided whether laryngeal phthisis (as 
it is termed) ever actually precedes the pulmonary disease. The gen- 
eral belief is that it is always secondary, and there is no doubt that 
at post-mortem examinations, laryngeal phthisis is never found unas- 
sociated with tubercles in the lungs. The laryngoscopy characters 
of laryngeal phthisis have been described under the head of chronic 
laryngitis. 

The presence of cough is one of the most constant and striking phe- 
nomena of phthisis. It generally commences early, and increases in 
frequency and severity with the progress of the disease. In the begin- 
ning it is usually short and hacking, and either dry or attended with 
scanty glairy expectoration. It is probably then due to slight bron- 
chial irritation only, and the discharge consists of bronchial mucus. 
With the advance of the disease, and the breaking down of the pul- 
monary tissue, the sputa usually become increased in quantity, often 
very profuse, and at the same time opaque, yellowish, or greenish, and 
purulent, often nummulated, sometimes fetid. The expectoration is 
not necessarily distinguishable from that of bronchitis. It is furnished 
partly by the inflamed bronchial tubes, partly by the tubercular vom- 
icae; sometimes, by careful microscopic examination, pulmonary tissue 
may be detected suspended in it. The cough itself presents no special 
characteristics by which it may be distinguished from that of bron- 
chitis, or (if the larynx be affected) from that of laryngitis. It is liable 
to considerable differences in different cases ; in some it is scarcely a 
matter of complaint from first to last; in some (especially chronic cases) 
it presents periodical variations, increasing, for example, in the winter 
or cold weather, subsiding in the summer-time ; but in the majority of 
cases it is a serious and increasing cause of distress. 

Haemoptysis is one of the commonest accidents of pulmonary 
phthisis. It occurs at some period or other in the course of the great 
majority of cases. Sometimes it is the first indication of the disease ; 
more frequently it comes on at a later period. It may be only suffi- 
cient to tinge or streak the sputa, or it may be limited to an occasional 
succession of sangu indent sputa, or, again, it may be sudden and pro- 
fuse — the patient bringing up in a very short time half a pint, a pint, 
or even a larger quantity of blood. It may, indeed, be so profuse at 



416 



DISEASES OF THE RESPIRATORY ORGANS. 



any stage of the disease that the patient is suddenly carried off either 
by choking or by syncope. 

Difficulty of breathing is a common but not necessary phenomenon. 
It may be severe if the larynx be largely affected, if there be much 
accumulation in the bronchial tubes, or effusion into the pleura?. In 
most cases, however, the patient makes little or no complaint on this 
score; he no doubt readily loses wind on even slight exertion, and 
habitually, perhaps, the respirations are more or less augmented in 
frequency, but when he is at rest his breathing does not usually trouble 
him. 

The patient often suffers from stitch, or burning, or other kind of 
pain in the chest. This may occur on one or both sides, often at one 
apex, but is not limited to any one part. Pain is by no means always 
present; some patients never experience it, others suffer from it occa- 
sionally only ; in some cases it is pretty constant and severe. It is 
usually augmented by movement of the chest, and especially by deep 
breathing or by coughing. It is mostly due to pleuritic complication. 

The physical signs of pulmonary phthisis are such as would natur- 
ally arise from progressive consolidation of the lung, associated with 
the formation of cavities, the accumulation of secretion in them and in 
the bronchial tubes, and pleuritic inflammation and exudation. In 
considering the significance of the physical signs we must never forget 
that, as a rule, tuberculosis commences at one or both apices of the 
lungs, that excavation usually first takes place in the same situations, 
and that the morbid processes tend to travel downwards. 

The presence of small discrete tubercles in the lungs, even if they 
be very numerous and close-set, does not necessarily affect the char- 
acter of the percussion-note or the sounds which may be heard on 
auscultation. We can, therefore, readily understand that pulmonary 
tuberculosis may become considerably advanced without giving distinct 
local indications of its presence, and we must not too readily assume, 
because we hear nothing amiss, that therefore the patient is free from 
tubercle, or that he is in the so-called " pre-tubercular stage/' Gener- 
ally, however, even if there be no dulness, there are bronchitic signs, 
rhonchus, crepitation, and the like, and these are probably more marked 
over the upper portions of the lungs ; or there may be occasional evi- 
dence of pleuritic friction ; or there may be here and there jerky re- 
spiratory sounds, which have sometimes been attributed to the presence 
of circumscribed patches of pleuritic inflammation. When, however, 
tubercles have coalesced into masses, say from the size of a walnut up- 
ward, and abut upon the surface, their presence materially affects the 
quality of the percussion-note over the area to which they correspond. 
There is then more or less marked dulness on percussion, the extent 
and completeness of which are determined by the extent and bulk of 
the consolidated tract. Dulness from tubercular disease is generally 
indicated by the facts that it occurs mainly at the apex in front or be- 
hind, that it is rarely equal in these situations, and still more rarely 
equal in the corresponding points of both apices, and that it tends j 
gradually to extend from above downwards, so as to involve more and 
more of the tissue of the lung. In association with the dulness there 



TUBERCULAR DISEASE. 



417 



is usually increased sense of resistance on percussion, increase of vocal 
fremitus, diminished movement during respiration, and more or less 
obvious flattening. The latter condition is especially noticeable when 
it occurs beneath the clavicle. The auscultatory phenomena at this 
stage are mainly those which attend the second stage of pneumonia — 
tubular breathing, together with (if the tubes contain secretion) rhon- 
chus, gurgling, crepitation, or occasional clicking or creaking sounds, 
bronchophony, and probably also pectoriloquy. It need scarcely be 
added that, if the consolidated patch be imbedded in the substance of 
crepitant lung, little or no indication of its presence may reach the ear. 
The phenomena which attend the formation of vomica? are very vari- 
ous, and by no means always characteristic. The presence of one or 
several small cavities in the midst of consolidated tissue does not obvi- 
ously modify the percussion note. Large cavities, indeed, may exist, 
surrounded by a thick layer of condensed lung-tissue, and yet almost 
absolute dulness may be present. In other cases, however, the forma- 
tion of a cavity in consolidated tissue is attended with the redevel- 
opment of resonance, which may become almost normal, or may be 
high pitched and tympanitic, or may present the characters of the bruit 
de pot file. On auscultation over cavities w T e may detect (if they con- 
tain fluid) large crepitation and gurgling — sounds which may also be 
heard over the larger bronchial tubes when imbedded in condensed 
lung-tissue — or (if they be empty) some modification of tubular breath- 
ing. Occasionally (and this may be the case in respect of cavities no 
larger than a walnut) we may hear distinct cavernous breathing. Me- 
tallic tinkling is rarely audible over tubercular cavities. In some cases 
no sounds whatever are produced within a cavity, and all that one 
hears are normal or abnormal respiratory sounds transmitted from the 
parts beyond. Both bronchophony and pectoriloquy may usually be 
recognized over cavities ; pectoriloquy, however, is on the whole more 
marked here than over solid lung, bronchophony less marked. 

In delicate patients in whom no obvious consolidation can be recog- 
nized, the persistent presence, at one or other apex, of a few clicking 
sounds, or of rhonchus, or of crepitation, or of jerky respiration, is 
ground for the gravest suspicion. By some physicians, moreover, a 
systolic murmur over the pulmonary artery and its main branches, or 
in the course of the subclavian artery within the chest, is equally re- 
garded as an indication of the presence of tubercular consolidation — 
the belief being that the murmurs are produced by the pressure of 
consolidated tissue upon the vessels in question. They are probably 
ansemic. 

The state and action of the circulatory organs are for the most part 
such as we meet with in all other chronic diseases, attended with pro- 
gressive enfeeblement. In the earlier stages of phthisis the pulse is 
usually increased in frequency and hardness ; with the advance of the 
disease its frequency becomes augmented, but there is diminution of 
fulness and of force. With increasing enfeeblement of the circulation 
it is not uncommon for some degree of anasarca to supervene, especially 
if the enfeeblement of the left side of the heart be associated, as it 
occasionally is, with hypertrophy and dilatation of the right side. As 

27 



418 



DISEASES OF THE RESPIRATORY ORGANS. 



a rale, however, the heart undergoes general atrophy. In many cases 
the anasarca is limited to the lower extremities, and is then often im- 
mediately due to thrombosis of the iliac veins. It is doubtless owing 
to the same enfeeblement of the circulation that various parts, and 
more especially the nose, ears, fingers, and toes, frequently become con- 
gested, livid, and tumid. A clubbed condition of the fingers and toes 
(although by no means confined to phthisis) is, as is well known, of 
common occurrence in the chronic form of the disease. Each ungual 
phalanx becomes swollen and bulbous, and at the same time more or 
less congested ; and in consequence of the grape-like form which it 
assumes, the nail, which occupies the upper half only, becomes bent 
over the summit, forming a kind of sloping roof to it. 

The symptoms referable to the stomach and bowels are generally 
of considerable importance. The tongue is often clean throughout the 
greater part of the patient's illness ; it is often, however, morbidly red, 
often more or less furred, and towards the fatal termination often be- 
comes dry, glazed, and fissured or aphthous. There is usually more 
or less thirst. The condition of the appetite presents great variations. 
In some cases the patient enjoys a good, and possibly voracious appe- 
tite ; in other cases the appetite is capricious ; while in others again 
there is complete anorexia and probably great irritability of stomach, 
with gastrodynia, nausea, and sickness. The latter conditions depend 
in some cases on catarrhal inflammation of the mucous membrane of 
the stomach, and are often associated with thinning and dilatation of 
that organ. Phthisical patients are exceedingly liable to suffer from 
diarrhoea, which is apt to be very obstinate and profuse, and often as- 
sumes a dysenteric character. Persistent diarrhoea, indeed, may be 
the most serious of all the morbid conditions from which the patient 
suffers. It is, in the great majority of cases, due to coincident ulcera- 
tion of the bowels, a lesion which complicates fully one-half of the 
cases of pulmonary phthisis, and which may outrun, if it do not pre- 
cede, the pulmonary disease. Diarrhoea may, however, be due, like the 
dyspeptic symptoms, to mere catarrh, or some other form of irritation 
of the mucous membrane. It is a well-recognized fact that tubercular 
patients are peculiarly apt to suffer from fistula in ano. The presence 
of a fatty liver is not usually indicated by symptoms, but may occa- 
sionally be recognized by the increased bulk which the organ attains. 

The nervous system does not usually present any very characteristic 
morbid phenomena. The patient may be more or less irritable, or, on 
the other hand, apathetic ; he is sometimes desponding, but very often 
indeed remarkably hopeful, buoying himself up even to the last with 
the prospect of eventual recovery. 

Hectic fever and gradual emaciation are by far the most important 
and striking of the general phenomena of phthisis. They commence 
in most cases long before the actual proofs of the growth of tubercles 
exist, and they continue, as a rule, throughout the whole duration of 
the disease. It is important, however, to observe that phthisical patients 
often undergo temporary improvement, that under judicious manage- 
ment they often gain flesh and strength, sometimes never lose flesh, and 
that they not unfrequently remain free from fever for days or weeks — 



TUBERCULAR DISEASE. 



419 



sometimes, indeed, have scarcely any febrile symptoms during the whole 
course of their illness. 

The hectic of phthisis is almost typical in the distinctness of the 
daily remissions and exacerbations which attend it. There is usually 
some elevation of temperature after food, especially after hearty meals, 
but the maximum mostly occurs in the afternoon or evening. The 
minimum temperature in the day may be normal, or even below the 
normal ; the maximum may reach anything from 101° to 104° or 105°. 
In most cases, however, the minimum temperature is still considerably 
above the normal, and the range less wide than the above figures might 
seem to indicate. Not uncommonly the temperature falls considerably 
as the fatal end approaches. The patient usually suffers during the 
periods of exacerbation from heat in the palms and soles, and flushing 
of the cheeks, which is for the most part vivid and circumscribed, and 
has received the name of the " hectic flush. " Perspiration is a common 
and distressing symptom. The patient complains little of this while 
he is awake, but when he is asleep it is apt to break out profusely all 
over him, rendering his surface damp and sodden, and his linen and 
coverings in some cases so wet that the moisture may be wrung out of 
them. These perspirations are sometimes absent, or they may inter- 
mit, or be so slight as to be of little significance. 

The emaciation of phthisis is intimately related to the presence of 
the hectic fever, both being the consequence mainly of the rapid dis- 
integration of the corporeal tissues. All parts of the body, doubtless, 
waste; some, however (especially the brain and nervous system), less 
than others. The heart dwindles, the bones and muscles become 
atrophic ; but the most obvious change is in the fat, which gradually 
and for the most part almost entirely disappears. The limbs and trunk 
consequently shrink, and their surface becomes wrinkled ; the skin of 
the face and forehead becomes closely applied to the subjacent bones 
and muscles, so that the cheek-bones, and especially the zygomatic 
arches, become remarkably prominent, and the movements of the 
muscles painfully visible. The skin itself in many cases grows thin 
and brittle, the nails dry and inclined to split, and the hair thin and 
scanty. In some cases, however, no such change in the cutaneous 
organs takes place, and indeed the hair occasionally becomes extraor- 
dinarily luxuriant. The extreme emaciation favors the development 
of bed-sores on the buttocks and in other situations. 

It need scarcely be added that, in a very large number of cases of 
phthisis, the presence of complications already adverted to — more 
especially cerebral, peritoneal, and renal tuberculosis, and degenerative 
affections of the liver and kidneys — adds other symptoms to those which 
have been enumerated, and naturally modifies the progress of the disease. 

Several varieties of phthisis, which do not necessarily correspond to 
the several varieties recognized by the pathologist, are described by 
those who look at the disease from the clinical point of view. They 
may be ranged, however, under the heads of acute and chronic phthisis. 

The great majority of cases of phthisis belong to the chronic category. 
They commence in one or other of the ways already indicated, and the 
general symptoms and local changes which have been above discussed 



420 



DISEASES OF THE RESPIRATORY ORGANS. 



become gradually established. In many cases the disease progresses 
uniformly, no amendment whatever takes places, and the patient sinks 
probably in from six to twelve months from the first manifestation of 
symptoms. In some cases the duration of the disease is greatly ex- 
tended. The patient suffers from the ordinary symptoms of phthisis, 
or it may be from those of a simple bronchial attack, and then appears 
to recover more or less completely; but after awhile the symptoms 
recur, and again amendment follows, and again and again, it may be, 
these alternations of illness and of comparatively good health take 
place, until at length the symptoms of the disease become continuous, 
and the patient gradually sinks. In such cases the tubercular process 
probably takes place in successive props ; and in such cases also is it 
that post-mortem we find intermingled extensive tracts of indurated 
and contracted lung-tissue, encapsuled mortary or cretaceous masses, 
cavities with cicatrized parietes, and more or less emphysema. Tuber- 
culosis, dependent on the constant inhalation of irritating matters, for 
the most part takes a similar course. It may be added, indeed, that 
when phthisis becomes thus chronic, it approaches, both in its morbid 
anatomy and in its symptoms, the lung-affection already discussed under 
the name of cirrhosis. In some such cases the progress of the disease 
becomes permanently arrested ; and then, in proportion to the degree 
in which the lung-tissue may have undergone disorganization, is the 
restoration to health complete or incomplete. 

In acute phthisis the patient may die of the disease in the course of 
a few weeks, and generally dies within three months. Two varieties of 
acute phthisis may be distinguished : first, that in which the tubercles 
are from the first mainly if not entirely yellow, and in which there is 
very rapid breaking down of lung-tissue ; and, second, that in which 
the tubercles are miliary. The first variety resembles the ordinary 
chronic forms of . phthisis in its symptoms, excepting only in their 
intensity and the extreme rapidity of their development. It usually 
commences suddenly with high fever and rigors, and pulmonary symp- j 
toms which have a close resemblance to those of ordinary pneumonia. 
It is in fact with this disease that it is especially liable to be confounded, j 
The second variety also comes on more or less suddenly with fever and 
rigors, and possibly, but not necessarily,, some bronchial irritation and 
cough. The symptoms indeed, both at the onset and for some time, 
sometimes throughout the whole course of the disease, have a marked 
resemblance to those of enteric fever with pulmonary complication. ! 
The state of the pulse, tongue, and cerebral functions may be identical 
in the two affections. In both the bowels may be constipated or loose ; 
in both there may be abdominal tenderness and tumefaction ; in both 
the febrile temperature shows marked remissions ; in both dyspnoea is 
apt to supervene, and the face to become ghastly or livid. The motions, 
however, are rarely peasoup-like in the tubercular disease ; the pain in 
the abdomen is less constant, and, if present, is due to peritoneal tuber- 
culosis, and therefore less localized ; the temperature does not present 
the uniform variations characteristic of enteric fever, and there is an I 
absence of the typical typhoid rash. The disease may prove fatal 
without the development of dulness, and without any evidence of the 



TUBERCULAR DISEASE. 



421 



formation of cavities. Usual]}', however, as the disease advances, the 
lungs undergo more or less consolidation, commencing at the apices 
and extending downwards. 

Death in phthisis is due in most cases to asthenia, generally of slow 
development, but sometimes rapid, and immediately referable either to 
extremely profuse alvine flux, or to sudden and severe haemoptysis. 
In some cases it may be referred in part or wholly to asphyxia. Such 
may be the cause of death in phthisis associated with laryngeal disease, 
or with much secretion into the bronchial tubes, or in which there is 
sudden effusion of blood into the air-passages. 

There are no symptoms by which tubercular pleurisy can be dis- 
tinguished from the simple inflammatory affection, apart from its 
intractable character, and the concurrent or consecutive appearance of 
'tubercles in other organs. 

Treatment. — It is of the first importance in the treatment of the early 
stages of phthisis, and indeed in the treatment of all persons in whom 
a tendency to phthisis appears to exist, to adopt every measure in our 
power to promote the general health, to take every precaution against 
the infraction of hygienic laws. It is obvious, therefore, that many of 
the details of treatment are such as, under the circumstances, common 
sense would dictate. We may, however, enumerate a few of the mat- 
ters here referred to. The diet should be wholesome and nutritious, 
and fairly distributed among the recognized meals ; the patient should 
keep good hours ; refrain from all overwork, whether mental or bodily ; 
clothe himself warmly, and live in temperate, well-ventilated, but not 
draughty rooms. At the same time he should not refrain from 
amusement ; nor need he abstain from business or other occupations 
if they be not too absorbing, or if they be not of an unhealthy nature; 
and he should (if the weather be suitable) take an ample amount of 
gentle outdoor exercise. 

Good milk and eggs are probably especially valuable as articles of 
food for phthisical patients, but in their dietary frequent changes and 
considerable latitude are often necessary; and, further, alcoholic stimu- 
lants, though probably not essential, are often apparently very bene- 
ficial. For the purposes of bodily warmth flannel should be worn 
next the skin. 

The question of change of air is at this time one of the most 
momentous that can be raised. Shall the patient leave his home, and 
if so, whither shall he go, and when ? The great desideratum for 
phthisical patients appears to be a climate of moderate temperature, 
liable to slight variations only, and neither largely saturated with 
moisture nor of extreme dryness. It is exceedingly rare, however, for 
any climate to possess such uniformity of qualities during the whole 
year, and it is generally, therefore, necessary, in order to secure the 
full benefit of climate, to change the locality according to the season. 
And hence it will be understood that while most fairly healthy inland 
or seaside places in this country may suit phthisical patients reasonably 
well during the warmer months of the year, it will probably be neces- 
sary to select some sheltered spot upon the South Coast for winter 
residence ; that, while the bracing atmosphere of Scotland or Sweden, 



422 DISEASES OF THE RESPIRATORY ORGANS. 

or of the higher regions of Switzerland and Tyrol, may be exceedingly 
suitable during the summer, the south of Europe, or the north of 
Africa, or the Azores or Canary Islands, may be especially beneficial 
during the winter. There is, however, large choice, and it may be 
added that a sea voyage is often of great service. But, notwithstand- 
ing the enormous benefits that not unfrequently accrue from judicious 
change of climate, or from the permanent removal to a locality which 
experience may have shown to be specially suitable for the patient, it 
must not be forgotten that such changes often entirely fail to do good, 
and that they are altogether uncalled for and useless when the disease 
is acute in its progress, or is far advanced. 

In addition to the above hygienic measures, and to the same end, it 
is generally advisable to have recourse to medicines. No drug with 
which we are acquainted has any specific influence over the tubercular 
process. But there are some drugs which, by improving the general 
health, tend indirectly to check its progress. Of these iron, quinine, 
and other vegetable bitters are amongst the most valuable. But there 
is one article — drug, or food — namely, cod-liver oil, which during the 
last thirty years has acquired a special reputation. There is little 
doubt on the part of practical physicians, none on the part of the public, 
of the great value of this in the treatment of phthisical and scrofulous 
patients. It may be given in doses of from a drachm to an ounce 
three times a day. It is generally, however, advisable to begin with 
a small dose in order to avoid the production of nausea, and prevent 
the patient from taking a dislike to it. It is now largely believed that 
the virtues of cod-liver oil depend simply upon the fatty matter of 
which it mainly consists ; and hence it has been assumed that other 
fats might prove equally beneficial. The use of cream, neats'-foot oil, 
olive oil, and other vegetable and animal fats, and of glycerin, has 
consequently been recommended. A great and sometimes insuperable 
bar to the administration of food and to the use of the remedies which 
have been enumerated, is the irritability of stomach which is so often 
associated with phthisis. Hence, in a large number of phthisical 
cases, the condition of the stomach claims our first attention. It is 
impossible to lay down special rules of treatment ; we must have re- 
course to some of the various measures which are serviceable in the 
more ordinary forms of dyspepsia, and above all perhaps we must 
adapt the tonic or combination of tonics we employ to the condition of 
the patient's stomach. 

A great part of the treatment of phthisis usually consists in treating 
symptoms as they arise. None of these symptoms is special to phthisis, 
and all may be treated in accordance with the rules which guide us in 
their treatment under other circumstances. Local pains must be ob- 
viated by counter-irritation; laryngeal affections by counter-irritation, 
by applications to the interior of the larynx, and by inhalation; cough 
and expectoration, according to circumstances, by expectorants, ipecac- 
uanha, and the like, or astringents, or sedatives; diarrhoea by lead, or 
tannic acid, or other of the numerous remedies which check intestinal 
secretion or assuage peristalsis. It must be added that, for the above 
and many other purposes, no one remedy is so generally useful as opium ! 



SYPHILITIC DISEASE. 



423 



in its various preparations; it relieves pain and discomfort, diminishes 
cough and expectoration, and restrains the action of the bowels. The 
nocturnal perspirations often defy treatment; to check them it is desi- 
rable that the patient should not be heavily laden with bedclothes, and 
that his room should be cool. The surface of the body too may be 
sponged before he goes to sleep. The mineral acids, oxide of zinc, and 
various other astringent remedies have been largely employed for the 
same purpose. Also food or wine given in the night shortly before the 
hour at which perspiration usually occurs seems occasionally to prevent 
it. With the object of arresting haemoptysis, the use of ice and ice-cold 
drinks and foods, and the administration of astringent drugs, especially 
digitalis, lead, ergot, and gallic acid, are usually advocated. 

In conclusion, it may be pointed out that while circumstances may 
occasionally arise to render the local abstraction of blood or the use of 
emetics or purgatives necessary, all depressing treatment is, as a rule, 
to be eschewed; that during the later period of the disease stimulants 
are often of extreme value; and, further j that in cases of acute phthisis 
tonics, cod-liver oil, and change of air are usually equally valueless. 



SYPHILITIC DISEASE. 

Morbid Anatomy. — 1. Larynx, trachea, and bronchial tubes. Syphil- 
itic affections of the larynx have been already briefly adverted to under 
the head of chronic laryngitis. The larynx may become the seat of 
erythematous inflammation during that period in which the skin is 
similarly involved. There may even then be some excoriation of sur- 
face. At a later period, usually, in the course of syphilis mucous 
tubercles become developed on various parts of the laryngeal surface, 
in common with that of the neighboring pharynx. These commence 
as small gland-like elevations of the mucous membrane, which gradu- 
ally extend and coalesce. They may appear at any part, on the epi- 
glottis, on the vocal cords, and especially (according to Dr. Mackenzie) 
on the inter-arytenoidean fold. They furnish a pretty abundant se- 
cretion, and tend to ulcerate, the ulceration extending both in surface 
and depth, and leading, according to its situation, to the more or less 
complete destruction of the epiglottis or of the vocal cords, and not 
unfrequently to caries or necrosis of the arytenoid, thyroid, or cricoid 
cartilage. During the so-called " tertiary period" of syphilis gum- 
mata appear beneath the mucous membrane, involving not merely the 
connective tissue but the muscles and other parts. In this way 
tumors of considerable bulk may be developed. These, like other 
gummata, tend to undergo rapid degenerative changes, and to end in 
the formation of deep unhealthy looking ulcers. All syphilitic ulcers, 
especially when they extend deeply, are apt to involve the destruction 
of the cartilages, to lead to communication between the larynx and 
the oesophagus, and to lay open arteries sufficiently large to allow of 
fatal haemorrhage; and all, when they heal, leave dense, reticulated 



424 



DISEASES OF THE RESPIRATORY ORGANS. 



cicatrices which not unfrequently produce serious contraction of the 
channel of the larynx. 

Similar affections to those just described may take place either in the 
trachea or bronchial tubes. There is reason to believe that a form of 
syphilitic erythema may attack the bronchial tubes; and there is no 
doubt that syphilitic thickening of the mucous membrane and gum- 
mata of their deeper tissues are not altogether unfrequent. These af- 
fections also in their further progress lead to ulceration, destruction of 
cartilages, and cicatrization with contraction. 

2. Lungs. — Syphilitic affections of the lungs are imperfectly under- 
stood. It is well known that syphilitic patients frequently become 
the victims of pulmonary phthisis, and the question has naturally pre- 
sented itself whether the apparently tubercular formations in such cases 
may not be really syphilitic. The question is not altogether easy of 
solution, for while, on the one hand, we have no reason to believe that 
the presence of syphilis excludes that of tuberculosis, on the other we 
know that there is a close anatomical resemblance between syphilitic 
gummata and tubercular formations. There is, however, no reasonable 
doubt that the lungs occasionally present specific syphilitic lesions, and 
that these commence with proliferation of the connective tissue of the 
organ, and terminate in the formation of patches from the size of a pea 
to that of a filbert, in which the tissue is more or less indurated and 
grayish, studded in some instances with caseous patches, and occa- 
sionally almost entirely converted into caseous matter. The caseous 
masses, however, in the lung, as elsewhere, though having a close 
resemblance to tubercles, are usually much less friable than these latter 
are. It may be added that such masses are usually associated with 
syphilitic affection of the bronchial tubes, that they commonly abut on 
the surface of the lung, and that the pleural surface corresponding to 
them is apt to be involved. Virchow and others have described a kind 
of white hepatization of the lungs of stillborn syphilitic children, the 
origin of which they refer to the syphilitic poison. The lung, or lungs, 
or large portions of them, are dense, yellowish-white, opaque, tough, 
but retaining the impress of the finger. They have been observed in 
association with syphilitic pemphigus. 

Symptoms and Progress. — The symptoms of syphilitic disease of the 
larynx are essentially the same as those which have been ascribed to 
chronic laryngitis. The affection, however, especially if it be con- 
nected with the formation of mucous tubercles or of gummata, is ex- 
tremely intractable, rarely terminating in complete restoration to health, 
and frequently leading to one or other of the graver lesions which have 
been enumerated. Syphilitic affections of the bronchial tubes similarly 
simulate in their symptoms ordinary chronic bronchitis. 

With the few clinical facts which we possess in reference to the sub- 
ject it would be a mere exercise of ingenuity to describe at length the 
symptoms which may be produced by pulmonary syphilis. It will be 
sufficient to say that the diseases with which it would be most likely to 
be confounded are chronic bronchitis, chronic phthisis, cirrhosis, and 
the consequences of these affections. The presence of a history of 



MORBID GROWTHS. 



425 



syphilis, and of the superficial indications of syphilis, would, of course, 
furnish an important element of diagnosis. 

Treatment — It need scarcely be said that, in treating syphilitic affec- 
tions of the larynx, trachea, bronchial tubes and lungs, our main trust 
must be placed in ordinary anti-venereal remedies. 



MORBID GROWTHS. 

Morbid Grroivths of Larynx. 

Morbid Anatomy. — The larynx is a not unfrequent seat of adventi- 
tious growths. Of non-malignant growths the most common are fibro- 
mata of different kinds. These may be either simple tumors of a 
rounded or lobulated form, more or less distinctly pedunculated, and 
varying, it may be, from the size of a filbert downwards; or they may 
be similar bodies associated with more or less obvious overgrowth of 
the mucous glands, or with the formation of cysts ; or they may be of 
a papillomatous or warty character. These last are far more common 
than the others. They rarely exceed the size of a horse-bean, and are 
not generally larger than a split pea. They are, however, often mul- 
tiple, and tend to spread over a considerable surface. Fibromata usu- 
ally originate on or in the vicinity of the vocal cords, but are not limited 
to these localities. They are not unfrequent in children, but may ap- 
pear at any age. 

Malignant tumors are mostly epitheliomatous, but are sometimes 
sarcomatous or cancerous. The first of these, which is the most com- 
mon, commences either in the pharynx, involving the laryngeal tissues 
secondarily, or at some part or other of the laryngeal surface. The 
others originate among the deeper textures. 

Symptoms and Progress. — The symptoms to which simple polypi 
give rise creep on gradually, and probably consist in a little hoarseness 
or loss of voice, with a tendency to clear the throat or to cough, and a 
feeling sometimes as if there were some foreign body in the larynx. 
The phenomena, indeed, are undistinguishable at this time, except by 
means of the laryngoscope, from those of ordinary subacute laryngitis. 
At a later period their presence gives rise to more or less complete 
aphonia, to more or less serious impediment to respiration, and finally 
to death from asphyxia. Occasionally, if the laryngeal tumor be large 
and pedunculated, the symptoms vary with its change of position ; and 
the tumor may even be seen at the back of the throat without instru- 
mental aid. 

Malignant growths commence, like other growths, insidiously, mak- 
ing little show and manifesting few symptoms ; and for awhile indeed 
there may be nothing to cause grave suspicion. Gradually, however, 
they involve adjacent tissues and organs, form tumors which from their 
mere bulk interfere with respiration and other necessary acts, undergo 
destructive changes which give rise to copious discharges, involve the 



426 



DISEASES OF THE RESPIRATORY ORGANS. 



epiglottis, the aryteno-epiglottidean folds, the vocal cords and other 
parts, and perhaps cause sinuses to form in the neck or openings be- 
tween the larynx and oesophagus. Sometimes they cause the erosion 
of arteries and sudden arterial haemorrhage. It must be added that 
carcinoma, commencing in the glandular or other tissues external to 
the larynx, occasionally involves that organ in the course of its exten- 
sion ; and sometimes, indeed, when these external tissues are largely 
infiltrated, the larynx becomes immovably imbedded in them and fixed. 
At the commencement it is difficult, if not impossible, to recognize the 
presence of carcinoma, even on laryngoscopic examination. The rapid- 
ity of the growth of the tumor, however, the progressive character 
and extent of the ulceration which attends it, the fetor of the discharge, 
and the gradual involvement of the concatenate glands, all tend finally 
to render the diagnosis clear. 

Treatment. — Previous to the use of the la^ngoscope, even simple 
tumors of the larynx were to a very large extent fatal. They were 
then rarely recognized ; and, being allowed to grow without let or 
hindrance, ended by producing fatal obstruction to respiration. With 
the laryngoscope, however, their recognition is, even if they be very 
small, comparatively easy, and their cure for the most part a matter of 
little difficulty. If they be small or pedunculated they may be re- 
moved by means of curved forceps of special construction — for those 
growing at the back or front forceps opening anteriorly and posteriorly; 
for such as grow at the side forceps opening laterally. In some cases 
they may be removed by knife-edged forceps or scissors. It is inex- 
pedient to employ much force, for the mere crushing which follows the 
attempt at removal often (especially if it be repeated) leads to atrophy 
of the growth. Occasionally, when the irritability of the larynx is 
extreme, or the patient is suffering from great dyspnoea, or under 
other special circumstances, it becomes essential to perform tracheotomy 
previously to operating on the larynx itself. Astringent and other 
applications to the interior of the larynx are of little or no use. It 
need scarcely be said that the treatment of malignant affections of the 
larynx can never be curative ; occasionally, however, some relief may 
be afforded by the various local measures which are serviceable in cases 
of chronic laryngitis. 

Morbid Growths of Lungs and Pleurce. 

Morbid Anatomy. — Non-malignant growths of the lungs and pleurae 
are of little pathological and still less clinical interest; malignant 
growths, on the other hand, are of great interest and importance. 
There is probably no form of malignant disease which has not been 
discovered at one time or other in the organs under consideration ; and 
probably each form has (apart from its microscopical characters) special 
peculiarities as to distribution, progress, and symptomatology. In the 
present state of our knowledge, however, it would be an excessive and 
needless, refinement to discuss them separately. 

Malignant disease either originates within the lungs, or extends to 
them by continuity from the mediastinum or other adjoining parts, or 



MORBID GROWTHS. 



427 



is secondary to similar disease of some distant organ. In the first case 
it usually constitutes a solitary mass ; in the second it often runs along 
the bronchial tubes; in the third it is for the most part multiple. 
These several features are, however, by no means characteristic. The 
morbid process begins in the connective tissue, and therefore either in 
the walls of the air-cells, or in the interlobular tissue, or in the course 
of the bronchial tubes and their attendant vessels, or in the thickness 
of the pleural membrane and of the subpleural tissue. 

When the growth extends along the bronchial tubes the connective 
tissue which surrounds them becomes infiltrated and thickened, and 
the tubes and vessels set, as it were, in solidified tissue. Moreover the 
walls of the bronchial tubes themselves become ere long involved : in 
some instances those parts only which are external to the cartilages, in 
some those only which are internal to them, but for the most part their 
whole thickness. The affection of the mucous surface manifests itself 
by the appearance of small, disk-like elevations, which are at first scat- 
tered, but soon run together, forming a uniformly elevated slightly 
translucent tract, from which all the normal longitudinal and other 
markings are more or less completely effaced. Although the form of 
the affection here described commences at the root of the lung, and is 
for the most part further advanced there than it is elsewhere, its dis- 
tribution is not always continuous ; but tracts of healthy and of diseased 
tissues and of healthy and of diseased tubes frequently alternate one 
with another. 

Malignant disease, attacking the pleura and the subpleural tissue, 
frequently appears in the form of small grayish lenticular thickenings, 
which have been likened to drops of tallow or wax. They are some- 
times so little prominent and so thin as to be scarcely visible ; some- 
times they form very distinct papular or tubercular elevations. In its 
further progress the former variety tends gradually to form tolerably 
uniform tracts of considerable extent ; the latter variety tends to the 
production of pedunculated outgrowths, which may hang singly or in 
clusters into the pleural cavity and may vary from the size (say) of a 
pin's head up to that of a bunch of currants, or that even of an orange 
or a cocoanut. Whenever the morbid growth commences in the tissues 
which surround the bronchial tubes, or in the subserous tissue, there 
is a tendency for it to extend into the substance of the lung along the 
interlobular septa, and consequently for the affected lobe to assume 
some of the characters which are so common in, and to some extent 
special to cirrhosis. 

In most cases malignant disease of the lungs shows itself in the form 
of one or more distinct tumors. These, while yet of moderate size, 
have a more or less rounded form, and if they abut on the surface often 
assume there the central depression and the tumid margin which are 
so common in hepatic cancer. When such tumors increase in size, as 
they usually do, with some rapidity, they grow more or less irregular 
in form, and, from the fact that they are then apt to become blended 
with the results of inflammation and of pulmonary haemorrhage, their 
limits are often difficult to define. It must be added that in the 
progress of extension of malignant disease from the bronchial tubes or 



428 



DISEASES OF THE RESPIRATORY ORGANS. 



pleura, it is not uncommon for distinct tumors to form here and there 
in the lungs. Malignant growths of the lungs, like those of all other 
organs, tend rapidly to undergo degenerative changes, and hence soon 
break down and form vomica?. Not unfrequently sloughing takes 
place in them, and masses of the morbid tissue may become detached. 

Symptoms and Progress. — The symptoms to which malignant growths 
of the intrathoracic respiratory organs give rise are, for many reasons, 
exceedingly variable. If the disease principally affects the serous mem- 
brane, the symptoms have a more or less close resemblance to those of 
ordinary pleurisy ; if the bronchial tubes be its main seat, the symp- 
toms naturally approximate to those of bronchitis; if tumors form, 
they may, if sufficiently large, alford the physical indications of con- 
solidation, and if they undergo softening, of the presence of vomicae, 
and may be attended with more or less abundant purulent or bloody, 
and probably fetid expectoration. Still it must not be forgotten that 
malignant growths, in the early period of their formation, not un- 
frequently give no sign whatever of their presence, and that the patient 
may seem in fair, if not in his ordinary robust health, up to the sudden 
supervention of some inflammatory complication or of haemoptysis. 

Malignant disease affecting the pleura generally ere long excites 
some inflammatory action, and the formation of false membrane, with 
temporary stitch and friction sound audible during respiration, and is 
probably always, sooner or later, attended with effusion of fluid. This 
effusion usually gives rise to no symptoms beyond those due to the 
compression which it exerts. It tends so to accumulate as to distend 
the pleura, and is persistent, always returning and generally with 
rapidity after paracentesis. It is mostly mere ordinary dropsical 
serum; in some cases, however, it is distinctly inflammatory, and may 
be purulent. It not unfrequently happens, especially if the adjoining 
lung-tissue be implicated, that it is mixed more or less copiously with 
blood, or that it is stained with altered blood-pigment, being green, 
yellow, or brown, or that it is glairy like the fluid from an ovarian cyst. 

When the bronchial tubes and the parts surrounding them are the 
chief seats of disease, the symptoms, as before indicated, are mainly 
bronchial. Assuming that the patient has never previously suffered 
from bronchitis, the symptoms would be characterized by their in- 
sidious approach ; but when so far developed as to be a source of dis- 
tinct discomfort they would differ little, if at all, from those of pro- 
gressive subacute or chronic bronchitis in some of their phases. There 
would at first probably be some difficulty of breathing, increased by 
exertion, with little or no distinct local evidence of lung disease, or at 
most a little localized sibilant or sonorous rhonchus. With the ad- 
vance, however, of the malady, secretion would take place from the 
affected tubes, and cough, with more or less abundant expectoration, 
would be superadded to the other phenomena. 

Small malignant growths within the lungs, even if numerous, yield 
no physical indications of their presence. They may, however, give 
rise to congestion, oedema, or actual inflammation in their vicinity, and 
may hence become revealed. Larger growths are often solitary, and 
limited therefore to one locality. They may involve the whole of one 



MORBID GROWTHS. 



429 



lobe, or even more, of a lung. These, like smaller growths, are often 
associated with other local morbid conditions, which increase their ap- 
parent bulk and add to the symptoms which the patient presents. 

When malignant growths are of sufficient size to become recogniza- 
ble by their physical indications, we find, in many cases, that there is 
dulness on percussion over the region which they occupy, and that 
there is a total absence of healthy respiratory sound, of tubular 
breathing, of all forms of rhonchus and crepitation, and of bronchoph- 
ony, pectoriloquy, and vocal fremitus. The local indications, indeed, 
are rather those which we are accustomed to regard as characteristic of 
pleural effusion than those which we usually associate with consolida- 
tion. The reason of this peculiarity lies in the fact that malignant 
growths usually form solid masses, the bronchial tubes which permeate 
them being compressed or otherwise obliterated, and that hence they 
are as distinct acoustically from the lung-tissue as is an accumulation 
within the pleura or the heart itself. There are many exceptions, 
however, to this rule, some clue to the presence of surrounding inflam- 
matory changes, some to the continued patency of tubes and to the 
greater or less abundance of secretion in them, some to the formation 
of vomicae in the interior of the morbid growths. The presence of 
malignant tumors in the lungs necessarily causes, sooner or later, more 
or less dyspnoea, more or less cough, and more or iess abundant ex- 
pectoration, which varies in its character, being sometimes at the 
beginning mere bronchial mucus, but later on becoming mucopuru- 
lent, and at length purulent, hemorrhagic, and fetid. The general 
symptoms which attend the progress of malignant disease of the lungs 
are, for the most part, those of gradually increasing debility and 
emaciation, often associated with those of hectic fever, the patient at 
length dying exhausted, and sometimes presenting before death typhoid 
phenomena. Death may, however, be due less to the progress of the 
cancerous growths than to the secondary phenomena, such as pleural 
effusion and bronchitic obstruction, to which they give rise ; and hence 
it may occur at a comparatively early period of the disease, or, at all 
events, before the opportunity for accurate diagnosis has presented itself. 

It has been assumed, in the foregoing account, that the disease has 
primarily or mainly implicated the lungs or pleuraB. It need scarcely 
be added that, when the thoracic affection is secondary to more ad- 
vanced disease elsewhere, it very often fails to reveal itself by symp- 
toms. Further, it will be readily gathered that the diagnosis of pul- 
monary or pleural malignant disease is often a matter of extreme 
difficulty — indeed, in most cases, it can only be arrived at by a very 
careful collation of all the facts of the case, and by close and con- 
tinuous observation of the patient's progress. The presence of malig- 
nant growths elsewhere of course furnishes a most important clue. 
This clue is not likely to fail in cases in which the pulmonary affection 
is secondary and comparatively unimportant. It may be absent, how- 
ever, from those cases in which its aid is most needed. Nevertheless, 
careful examination should be made from day to day, for very often 
indeed in the progress of such cases the enlargement of glands at the 
root of the neck, in the axilla or in the thoracic parietes, or the devel- 



430 



DISEASES OF THE RESPIRATORY ORGANS. 



opment of growths in connection with the ribs or the connective tissue 
of the thoracic walls becomes manifest, and throws a new and impor- 
tant light upon phenomena which were hitherto obscure. 

Treatment. — The treatment of malignant disease of the lungs and 
pleurae needs no special description. The treatment, already considered, 
of pleuritis, bronchitis, and pneumonia includes in some measure that 
of the several affections which have just been discussed — with the im- 
portant reservation that all that can be done for malignant disease is 
by palliation, and that therefore lines of treatment which may be pushed 
with advantage in the case of the inflammatory affections must be cau- 
tiously followed in respect of their malignant counterfeits. The relief 
of pain and discomfort, and the administration of nourishment, should 
be our chief aims. 



PARASITIC DISEASE. 

Morbid Anatomy. — The only parasites involving the lungs which are 
of practical interest are hydatids, and these are of exceedingly rare occur- 
rence in England. There is usually only one tumor present, and this 
is said to be most commonly situated in the lower part of the right lung. 
The hydatid tumor may attain the size of a large cocoanut or beyond ; 
may be situated (as it usually is) wholly within the substance of the 
lung; or, originating beneath the visceral pleura, may form, as it were, 
an outgrowth from the lung into the pleural cavity. The walls of the 
cyst which contains the parasite vary in thickness and density. The 
parasite itself is usually solitary, containing echinococci but not secon- 
dary hydatids. Hydatids of the lungs, like hydatids elsewhere, are 
liable to cause serious consequences either by the mere pressure which 
they exert, or by undergoing suppuration, or by discharging their con- 
tents into the pleural cavity or into the bronchial tubes ; they are also 
liable to undergo degenerative changes with gradual contraction and 
calcification. 

Symptoms and Progress. — Hydatid tumors of the lungs, when small, 
occasion little or no uneasiness, and necessarily therefore fail to be rec- 
ognized. But as they enlarge they are very apt indirectly to cause 
bronchitic symptoms and occasional attacks of more or less profuse 
haemoptysis, and thus a series of symptoms which are exceedingly liable 
to be mistaken for those of phthisis. Their recognition may be ren- 
dered possible either by the special features of the tumors to which they 
give rise, or by the sudden expectoration of their contents. An hydatid 
tumor is always very tense, and of a globular or ovoid form, and hence, 
when it attains any considerable size, tends, on the one hand, to cause a 
circumscribed bulging of the thoracic parietes with widening and more 
or less protrusion of the corresponding intercostal spaces, and, on the 
other hand, to displace the mediastinum and the diaphragm. The lo- 
calized bulging of the chest-wall, with the possible detection of fluctua- 
tion, and the circumscribed dulness on percussion which probably trans- 



PARASITIC DISEASE. 



431 



gresses the median line of the thorax, without extending at the same 
time to its summit, are strongly indicative of the presence of a pulmo- 
nary hydatid. There will also be over the area of dulness total absence 
of respiratory sound and of vocal fremitus. It is stated that the voice 
sometimes presents over the tumor an aegophonic character. It need 
scarcely be insisted that the signs above enumerated are not absolutely 
pathognomonic of hydatids ; they may be equally present (occasionally 
at least) in cases of circumscribed empyema or of solid tumors. The 
rupture of an hydatid cyst and the escape of its contents into the bron- 
chial tubes is attended with sudden suffocative cough and the profuse 
expectoration of fluid, which may, according to circumstances, be limpid 
and watery or purulent, and may contain either echinococci or fragments 
of hydatid membrane or both. The detection of the parasites, either 
by the naked eye or the microscope, necessarily removes all doubt as to 
the nature of the case. 

Hydatid tumors not unfrequently undergo cure — sometimes by spon- 
taneous retrogression, sometimes after the discharge of their contents 
by the bronchial tubes or some other route. On the other hand, the 
patient may die either suffocated by the sudden irruption into the 
bronchial tubes, or as a result of long-continued suppuration, or from 
the rupture of the cyst into the cavity of the pleura and consequent 
empyema. 

It is in many cases impossible to distinguish accurately between hy- 
datid tumors of the base of the right lung and those developed in the 
upper part of the right lobe of the liver. For the latter protude far 
into the base of the chest, displacing the diaphragm and base of the 
lung upwards, and cause marked bulging and dulness of the corre- 
sponding region of the thorax. Moreover, they are very apt to per- 
forate the diaphragm and to open either into the pleural cavity or into 
the lung itself, and in the latter case to discharge their contents by 
expectoration. When, however, hepatic hydatids are expectorated, 
biliary coloring matter is usually sooner or later mingled with them. 
On the other hand, hydatid abscesses of the base of the lung may per- 
forate the diaphragm and so lead to the formation of abdominal ab- 
scesses. 

Treatment. — There is little room for special treatment in the case of 
pulmonary hydatids. When they are recognized as forming obvious 
tumors, they may be treated on the same principles as hydatid tumors 
of the liver — a subject fully considered later on. 



BEONCHIECTASIS. {Dilatation of Bronchial lubes.) 

Causation and Morbid Anatomy. — It is theoretically an easy matter, 
but practically very difficult, to draw the line between simple dilata- 
tion of the bronchial tubes and vomica? which have become lined with 
a smooth membrane, and are in direct continuity with bronchial tubes. 
We make this distinction incidentally only, for our description of 



432 



DISEASES OF THE RESPIRATORY ORGANS. 



dilated tubes will embrace without distinction the several morbid con- 
ditions which are commonly confounded under the term. 

Dilated tubes then (using the term in its widest sense) may be 
arranged in three categories : first, that in which the dilatation involves 
the tubes in their whole length, and is consequently cylindrical or 
moniliform ; second, that in which it affects the terminal portions only 
of the tubes, and assumes a globular form ; and third, that in which 
the expansions are large, more or less irregular in shape, and communi- 
cate with one or more bronchial tubes. 

1. In the first of these varieties, the dilatation, which usually com- 
mences in the tubes of the first or second order, is continued thence, 
with little or no interruption, through the succeeding tubes almost to 
their terminations in the air-cells. It is generally relatively greater in 
the smaller than in the larger tubes ; the larger tubes indeed being 
often scarcely implicated, while the smaller may measure from J- to J 
inch or more in diameter. Hence the affected tubes form in some cases 
a series of hollow cylinders of nearly uniform calibre; in other cases a 
series of channels which actually increase in diameter towards their 
distal extremities, where probably they undergo in addition sudden and 
considerable enlargement. The dilatations are, however, rarely entirely 
uniform, but generally present a somewhat irregular or moniliform 
condition. The parietes of the affected tubes vary in character; some- 
times they are thickened generally, sometimes they are exceedingly 
thin and delicate, sometimes the mucous membrane is thick, congested, 
and pulpy. In the larger tubes it often happens that the fibrous and 
muscular bands stand out in strong relief, the interstices being conse- 
quently much deeper than natural, and occasionally forming distinct 
pouches. This form of dilatation rarely involves both lungs at the 
same time, and still more rarely the whole of one lung. It is most 
frequently met with in the lower and middle lobes, but even then is 
usually restricted to certain of their tubes only. The dilated tubes are 
in some cases surrounded by fairly healthy, in some by emphysematous, 
in some by collapsed lung-tissue. Cylindrical dilatation of the bron- 
chial tubes is probably always secondary to chronic bronchitis, and 
more especially to capillary bronchitis with abundant accumulation of 
fluid; and is primarily clue to the concurrence of inflammatory enfeeble- 
ment of the bronchial walls, and their distension by accumulated fluid 
contents. 

2. In the second variety, the expansion is almost exclusively limited 
to the terminal portions of the smallest bronchial tubes and the bron- 
chial passages. The dilatations are globular or nearly so in form, and 
vary perhaps from the size of a small pea up to that of a filbert ; they 
present a smooth internal surface, their parietes are comparatively thick, 
dense, and opaque, and for the most part they communicate severally 
with a single bronchial tube, the orifice of communication with which 
is sometimes small and difficult to find. In some cases such dilatations 
are scattered irregularly throughout emphysematous or otherwise dis- 
eased lung-tissue ; in some cases they are grouped more or less thickly 
in some corner of a lung ; or they may involve the whoje of one lobe, 
or even of one lung. The lower lobe is most frequently affected. In 



BRONCHIECTASIS. 



433 



the best-marked cases the whole of the lung or of its lower lobe is 
found diminished in size, and riddled with globular cavities which are 
separated from one another by airless, collapsed, indurated lung-tissue. 
The history of these cases is usually very obscure ; but there is good 
reason to believe that they originate, not in ordinary chronic bronchitis, 
but either in atelectasis, collapse, lobular pneumonia, or other such 
conditions. And it is probable that, in the first instance, the accumu- 
lation of mucopurulent fluid or of pus within the terminal bronchial 
tubes leads to the destructive ulceration of their walls and in a greater 
or less degree of the tissues which surround them ; that thus small 
cavities or vomicae, communicating with tubes, are formed within the 
solidified tracts of lung-substance; and that finally each cavity attains 
a certain size, assumes a definite form, and becomes lined with a mem- 
brane continuous with that of the bronchial tubes. 

3. The third variety comprises those cases in which the lung-tissue, 
more or less indurated, is the seat of one or more cavities of irregular 
shape, and various, but often considerable size, which open freely into 
one or two bronchial tubes. In some instances these cavities are soli- 
tary, situated in the apex, base, or elsewhere in the substance of the 
lung, and surrounded by or imbedded in dense fibrous or cicatricial 
tissue. In other instances the whole of one lobe, or the whole of a lung, 
contracted and cirrhosed, is studded with them. They are often lined 
with a perfectly smooth, polished membrane, continuous with that of 
the communicating bronchial tubes, but sometimes exhibit a more or 
less eroded or flocculent surface. In some cases they and the bronchial 
tubes connected with them present a thick, pulpy, deeply-congested 
lining, which may perhaps be undergoing excoriation. These cavities, 
strictly speaking, are not of course simple dilatations of tubes, but 
obviously originate in vomica?, tubercular, pneumonic, gangrenous, or 
other. They are always surrounded with a greater or less abundance 
of indurated tissue, and in a considerable number of cases are associated 
with obvious or advanced cirrhosis. 

The determining cause of the various forms of bronchiectasis which 
have been considered is no doubt disease involving the bronchial tubes 
themselves — disease attended with softening or destruction of their 
walls, and distension from undue accumulation of fluid within them. 
Yet it cannot be denied that other influences co-operate in some degree 
with these, the most efficacious of them, doubtless, being the constant 
tendency of a retracted side to recover its form, partly by its inherent 
elasticity, partly under the influence of the inspiratory efforts. It 
must be remarked, however, that this latter influence can scarcely be 
operative unless the lung-tissue generally be indurated and reduced in 
bulk, and that in spite of it many vomica? (as is well known) contract, 
and some possibly cicatrize. 

Symptoms and Progress. — It will probably be gathered from the 
foregoing account of the morbid anatomy and causation of bronchiec- 
tasis that its special symptoms are in almost all cases necessarily mixed 
up with those of the maladies out of which it arises and with which it 
is associated. It may be added that its own symptoms are not very 
characteristic. Those which may more especially be looked for are 

28 



434 



DISEASES OF THE RESPIRATORY ORGANS. 



shortness of breath and cough, with abundant mucopurulent expecto- 
ration, not unfrequeiitly mingled with blood, and occasionally fetid 
with a fetor which is little, if at all, distinguishable from that of gan- 
grene. This is believed to be due to decomposition of the retained 
sputa. The physical signs which probably present themselves are 
more or less retraction and immobility of one side or of a portion of 
one side of the chest, dulness on percussion, with large crepitation or 
gurgling, and other indications of the presence of Vomica?. It must 
not be forgotten, however, that difficulty of breathing may be scarcely 
noticeable if one lung continue perfectly healthy, and that distinct 
indications of the presence of cavities are not likely to be observed if 
the cavities be small or deeply-seated and surrounded with compara- 
tively healthy tissue. Profuse and repeated attacks of haemoptysis, due 
to intense inflammation and congestion of the lining membrane, or to 
its erosion, are not uncommon in the last of the three varieties of bron- 
chiectasis, and occasionally cause death. The diagnosis of dilated tubes 
rests on a careful consideration of the history of the case, on the slow 
progress of the pulmonary lesion, or its limitation to one lung, and 
often to its lower half, and on the profuseness, long continuance, and 
often fetor of the expectoration. 

Treatment. — No special treatment is required in bronchiectasis. For 
the most part the rules which have been laid down for the treatment 
of chronic bronchitis are applicable here. 



EMPHYSEMA. 

Causation and Morbid Anatomy. — Emphysema is due to the dilata- 
tion and rupture of the air-cells of the lungs. Two forms of it have 
been described, namely, the interlobular and the vesicular, in the former 
of which air is extravasated into the interlobular spaces, whilst in the 
latter the dilated and ruptured vesicles communicate with one another 
only. v \ : ■ m 1 : J ! 

Interlobular emphysema takes place only in those cases in which 
the pulmonary lobules are separated from one another by distinct in- 
tervals occupied by connective tissue. This anatomical peculiarity 
exists in the lungs of young children and in those of some of the lower 
animals, but is absent from the lungs of human adults. Interlobular 
emphysema is, therefore, a phenomenon of childhood only, and is occa- 
sionally observed, post-mortem, in cases of hooping-cough, lobular 
pneumonia, and capillary bronchitis, especially in those cases in which 
there have been repeated violent paroxysmal attacks of coughing. The 
escape of air into the interlobular spaces is indicated anatomically by 
their marked dilatation and their occupation by what looks like a 
series of air-bubbles. The degree in which emphysema is present 
varies greatly. In some cases, on section of the lung, merely a line or 
two of emphysematous tissue is observed. In other cases the lobules are 
more or less extensively isolated from one another by a network of 



EMPHYSEMA. 



435 



such tissue, and a similar mapping out of them may be recognized on 
the surface of the lung. Occasionally it happens that the emphysema- 
tous condition extends along the connective tissue which surrounds the 
bronchial tubes to the root of the lung, and thence diffuses itself into 
the mediastina, neck, face, trunk, and elsewhere. It may be added 
that the latter phenomenon is more frequently the result of gross me- 
chanical injury than of infantile pulmonary disorders; and that under 
such circumstances it is observed in adults as well as in young children. 

Vesicular emphysema is a much more common and, on the whole, 
a much more serious affection than the last. It occurs, with certain 
differences of character, under a variety of conditions. Thus it is not 
unfrequently met with in the lungs of persons dead of acute bronchitis; 
it is an all but universal attendant on the chronic form of that disease; 
it is one of the lesions which often accompany old age ; it is a frequent 
associated phenomenon of the obsolescence of tubercular masses, or of 
the contraction, from whatever cause, of circumscribed portions of lung ; 
and it occurs also, as we believe, as a sequela, of the obsolescence of 
scattered miliary tubercles. Under most of these conditions, it need 
scarcely be said, there is, or has been, persistent cough ; under several 
of them, enfeeblement of the walls of the air-vesicles or their involve- 
ment in the progress of destructive processes. 

1. The lungs of persons dead of acute bronchitis are very often 
found much distended with air. They completely fill the portions of 
the thoracic cavity allotted to them, and do not collapse even after they 
are removed from the body. The air-vesicles generally are distended 
to the full, and the lung-tissue cousequeutly is light, pale, and un- 
usually spongy. This condition is always associated with obstruction 
of the bronchial tubes by bronchitic secretion, and is primarily due 
to the comparative facility with which air is then drawn into the ulti- 
mate tissue of the lungs during inspiration, and the comparative diffi- 
culty with which it is then discharged during expiration. The appear- 
ance here referred to is very commonly regarded as an indication of 
emphysema. It is obvious, however, that there can be no disease of 
the air-cells, no vesicular emphysema, so long as the air-cells are simply 
distended and their walls remain sound. But when, as often happens, 
textural changes are superadded, when the walls of the air-cells become 
attenuated, bulging, perforated, and intercommunications between 
neighboring cells established, emphysema is really present. Never- 
theless, it is not always easy, either with the naked eye or the micro- 
scope, to diagnose between mere overdistension of the air-cells and 
the commencement of actual emphysema. 

2. The lungs of patients who have long suffered from chronic bron- 
chitis are almost invariably emphysematous in a greater or less degree. 
When the emphysema is advanced and well developed the lung is 
usually of large size and exceedingly irregular in form — the increase 
of size and the irregularity being both due to the formation of clusters 
of emphysematous vesicles, which cause lobular, and in some cases 
pedunculated, protrusions from various parts of the surface. These 
are usually most abundant upon the anterior and outer surfaces of the 
lung, and especially upon its diaphragmatic aspect. If the lung be 



436 



DISEASES OF THE RESPIRATORY ORGANS. 



full of air, the prominence of these clusters is unmistakable, and the 
relatively enormous size of their vesicles obvious on even casual in- 
spection. On section, the emphysematous tissue collapses much more 
readily than the healthier tissues around. If the distended lung be 
dried, before section, the distribution of the emphysema, not only at 
the surface but in the interior of the lung, may be easily recognized. 
The emphysema of chronic bronchitis has its origin, no doubt, in the 
emphysema of the acute disease, and comparatively slowly attains ex- 
treme development. It too, like the last, consists essentially in the 
attenuation and perforation of the walls of the air-cells, the distension 
of the multilocular cavities thus produced, and the atrophy and disap- 
pearance, to a large extent, of the capillary networks of the affected 
regions. The emphysematous blebs may, roughly speaking, vary in 
size from that of a tare or pea up to that of a filbert or walnut. 

3. It is not uncommon to find a certain amount of emphysema in 
the lungs of old people who have never materially suffered from bron- 
chitic symptoms. The emphysema here, however, is rarely extensive, 
and is often limited to the formation of fringes of emphysematous 
vesicles along the anterior and other sharp edges of the several lobes, 
and to the appearance of solitary vesicles scattered thinly over the 
general surface in connection with black pigmentary patches. When 
tubercular and other indurations and contractions take place in relation 
with any part of the pulmonary surface, so as to cause irregularity, 
puckering, and Assuring, well-marked emphysema (differing in no 
respect, exce])t in its distribution, from that of chronic bronchitis) 
almost invariably manifests itself in the comparatively healthy tissue 
in the immediate vicinity. This variety of emphysema is most com- 
mon at the apex. Again, emphysema arises in general but compara- 
tively slight chronic disorganization of the lung-tissue, general slight 
cirrhosis, or the obsolescence of widely distributed miliary tubercles. 
In these cases, as has been previously pointed out, the lung-texture is 
coarse, permeated by a fine network of what looks like cicatricial tis- 
sue, in the meshes of which the dilated and ruptured air-cells are con- 
tained. 

The aetiology of emphysema is a subject of considerable interest, 
and has largely occupied the attention of medical men. The theories 
which have been proposed in reference to it may be divided into three 
groups, the first of which attribute it to the force exercised during the 
act of inspiration, the second to the force exerted during the act of ex- 
piration, the third to nutritive impairment of the walls of air- vesicles. 

1. When we consider that the healthy lung is accurately adapted to 
the cavity which contains it, and that no enlargement of the chest 
voluntarily effected can possibly dilate injuriously the healthy lung 
within it, it is impossible to conceive that the emphysema of at least 
uncomplicated bronchitis can be referred to the force with which the 
lungs are inflated. Matters are, however, somewhat different when a 
lung, wholly or in part reduced in bulk by pleuritic adhesions or by 
textural changes, is subjected to the rhythmical efforts of the corre- 
sponding thoracic wall to expand. It is conceivable then that, while 
those parts of the lung which are most firmly compressed or most dense 



EMPHYSEMA. 



437 



from consolidation would undergo little or no consequent change, those 
which are comparatively little compressed, or which are still fairly 
crepitant, might undergo disproportionate expansion, that their air- 
cells might dilate, and their parietes become attenuated and finally 
ruptured. This, indeed, is the explanation commonly assigned to that 
form of emphysema which becomes developed in the vicinity of obso- 
lescent tubercular masses and other patches of contracted indurated 
lung-tissue. It may be observed, however, on the other hand, that 
when, in lungs bound down and compressed by dense adhesions, por- 
tions of lung where the adhesions are thinnest expand and protrude 
beyond the general level, emphysema is certainly not commonly ob- 
served. 

2. During ordinary expiration, when the lung-texture retains its 
normal elasticity, and the bronchial and other passages are freely per- 
meable, the air-cells are subjected to very little pressure. In all those 
acts, however, in which with closed glottis the expiratory muscles are 
called into vigorous action, the pressure on the surface of the air-cells 
and air-passages becomes augmented, and in some cases very greatly 
augmented. The acts to which we here refer are, in ascending order, 
speaking and shouting, the blowing of wind instruments, the expira- 
tory shocks of coughing, and the straining efforts which attend defe- 
cation, parturition, and other forms of violent muscular exertion. 
But in these cases, again, if the passages are permeable the pressure is 
uniformly distributed, and injury to air-cells is little likely to result 
unless some of them have been previously impaired as to their power 
of resistance by morbid changes. The conditions are altogether differ- 
ent when violent expiratory efforts are made, and made habitually, in 
the presence of obstructive disease of the bronchial tubes themselves, 
whether the obstruction be due to accumulation of mucus or other 
matters within them, to thickening of their mucous membrane, or to 
their compression by morbid formations external to them. For it is 
easy then to see that while, during violent expiratory efforts, large 
portions of the lung become comparatively empty, those portions 
(scattered among them probably) whose tubes are completely obstructed 
remain distended, and become in consequence unduly exposed to the 
compressing force exerted by the thoracic parietes. For equal extents 
of surface a globe holds a larger amount of contents than any other 
solid figure : it is obvious, therefore, that if a full globe be compressed 
it must either yield or burst. The same remark applies to a distended 
air-cell or to a group of distended air-cells ; and hence it is obvious 
that the effect of the expiratory compression of groups of full air-cells 
in connection with obstructed tubes must necessarily result in the ex- 
pansion and attenuation of their walls, and sooner or later probably in 
their rupture. It is, doubtless, to this cause, in large measure, that the 
emphysema of bronchitis and the interlobular emphysema of childhood 
are due. 

3. Many years ago Mr. Rainey demonstrated the occurrence of fatty 
degeneration in the walls of the dilated air-cells in some cases of em- 
physema. We have already alluded to the occurrence of emphysema 
in connection with cirrhosis and obsolescent miliary tubercles. But 



438 



DISEASES OF THE RESPIRATORY ORGANS. 



indeed it will be admitted without further formal proof that the walls 
of air-cells are liable to become weakened and to lose their ready dis- 
tensibility under different conditions, such as old age, and various 
forms of inflammatory and other influences. It is too obvious to need 
argument that enfeeblement of the walls of the air-cells must power- 
fully co-operate with the mechanical causes already discussed in the 
production of emphysema, and must, especially when of partial dis- 
tribution, render even normal violence of expiration a source of danger. 
In concluding this brief discussion of the causes of emphysema it 
must be added that, although we have considered them separately, 
they probably always act more or less in concert. Thus, before the 
expiratory acts can cause compression and rupture of groups of air- 
cells, these must have been distended with air by more or less power- 
ful efforts of inspiration ; and, even if the air-cells were previously 
healthy, their mechanical extension, attenuation, and laceration must 
result in the more or less serious impairment of their powers of resist- 
ance for the future. 

Symptoms and Progress. — Emphysema in its slighter degrees is often 
present without causing distinct symptoms. Thus, in the limited em- 
physema which attends the obsolescence of tubercle, and in that which 
supervenes during old age, there is often absolutely no sign to indicate 
its presence; and, even in the emphysema of bronchitis, there are often 
at first, and even for a considerable time, no phenomena apart from those 
of persistent bronchitis to justify its diagnosis. When, however, em- 
physema becomes considerable either in degree or extent it can scarcely 
escape recognition, notwithstanding the fact that even then its symptoms 
are mainly those of bronchitis. 

The physical signs of advanced emphysema comprise alterations in 
the form and movements of the chest, together with percussive and 
auscultatory peculiarities. The chest tends to become dilated in all 
its dimensions, rounded from above downwards as well as horizontally, 
the ribs at the same time acquiring a less oblique direction than in 
health ; the form which the chest assumes is that to which the term 
" barrel-shaped " has been applied. The shoulders become elevated, 
and the muscles of expiration (more particularly those of the neck 
and shoulders) unduly prominent. At the same time the limits of the 
respiratory movements become narrowed, the chest during expiration 
retaining still the distended or barrel-like condition, and during inspi- 
ration undergoing little enlargement. On percussion there is usually 
increase of resonance, or rather perhaps heightened pitch of percussion 
note, over the chest, and more especially over those portions of it 
which correspond to emphysematous arese; and the precordial dulness 
is diminished in extent, or even abolished. The respiratory sounds 
are enfeebled. 

The symptoms referable to the lesion are shortness of breath, in- 
creased on exertion, and culminating at times in asthma-like attacks; 
duskiness and pallor of skin, and tendency on the slightest exposure to 
suffer from bronchitic attacks. Further, there is usually feebleness of 
pulse, and tendency to emaciation. The presence of any considerable 
amount of emphysema seriously interferes with the readiness of trans- 



CONGESTION. 



439 



mission of the blood through the lungs, and hence the right side of the 
heart tends to become hypertrophied and dilated, the cervical and other 
systemic veins to get distended with blood, the circulation to be impeded 
in the capillary vessels of the extremities and internal organs, and gene- 
ral anasarca, congestion of liver with jaundice, and congestion of kid- 
neys with albuminuria, to supervene. Indeed the consequences of 
emphysema are almost identical (excluding congestion of the lungs) 
with those of mitral valve disease. 

Treatment. — The treatment of emphysema must necessarily be indi- 
rect. We cannot, either by drugs or otherwise, restore the affected 
air-cells to their former condition. What we can do, in many cases, is 
by appropriate medicinal and hygienic treatment to cure or relieve the 
bronchitis which is so often associated with it, to prevent the recur- 
rence of such attacks for the future, to relieve cough and dyspnoea, 
and to promote the general health. In addition, we may forbid all 
violent exercise and overexertion. Easy circumstances, early hours, 
wholesome but not excessive diet, gentle exercise, warm clothing, a 
genial climate, together with the careful avoidance of everything 
calculated to give cold, constitute the main elements in the successful 
management of those who suffer from emphysema. For the treat- 
ment of its complications we must refer to what is said under their 
respective heads ; and especially we must refer to the articles on bron- 
chitis and asthma. 



CONGESTION. 

This condition always coexists with inflammation. It frequently 
occurs, however, under other circumstances ; and it is this variety that 
we propose now to consider. 

1. Congestion of the Larynx , Trachea, and Bronchial Tubes. — Simple 
hyperemia of the larynx, trachea, or bronchial tubes may result from 
obstructive disease of the right side of the heart or any other condition 
which causes accumulation of blood in the veins which lead from these 
parts, or it may be a sequela of repeated attacks of inflammation. Of 
itself it is probably unimportant, leading at most to some increased se- 
cretion from the mucous surface and its glandular follicles, and to ha- 
bitual tendency to cough and hawk, especially on rising in the morning. 
It is chiefly serious because its presence greatly increases the liability 
to inflammation. 

2. - Congestion of the Lungs. Causation and Morbid Anatomy. — 
Congestion of the lungs is an expression in constant use, but is proba- 
bly generally applied to cases of bronchial or pulmonary inflammation. 
Simple congestion is, however, of frequent occurrence, and is often a 
serious complication of other morbid conditions. It is an early and 
serious result of mitral valve disease, and generally ensues sooner or 
later on other forms of disease affecting the left side of the heart. It 
is also a frequent complication of typhus and other infectious fevers, 
and even of the typhoid state. It doubtless also continues in some 



440 



DISEASES OF THE RESPIRATORY ORGANS. 



cases for a longer or shorter period after the subsidence of inflamma- 
tion. Congestion secondary to heart disease is for the most part gen- 
eral, and is often followed by rupture of the small vessels of the lungs 
and extravasation of blood. It leads consequently to the condition 
known as pulmonary apoplexy and to haemoptysis. Further, it not 
unfrequently also leads to the development of pneumonia. The con- 
gestion which takes place in the course of fevers is commonly termed 
" hypostatic," from the fact that it particularly affects the dependent 
parts of the lungs. It is due, like the congestion which, in the same 
affections, occurs in other depending parts of the body, to feebleness of 
circulation and the tendency which, under such circumstances, the 
blood has to yield to the influence of gravity. The affected portions 
of the lungs become dark, almost black, with congestion, ©edematous 
also, and more or less devoid of air ; but they maintain their bulk, are 
unusually heavy, crepitate in some degree, and are very lacerable. 
Not unfrequently this condition passes into pneumonia, and even into 
gangrene. Congestion of the lungs, whether in connection with heart 
disease or febrile states, is always a matter of serious importance, 
partly because it indicates that there is something in the stage or 
nature of the malady which threatens danger, partly because it gives 
rise itself to serious symptoms, partly because it is apt to end, as the 
case may be, in pulmonary apoplexy, gangrene, or inflammatory con- 
solidation. 

Symptoms. — The evidences of congestion are mainly the supervention 
of difficulty of breathing, with more or less lividity, and other as- 
phyxial phenomena, probably cough and watery expectoration, and also 
the presence of crepitating rales either generally distributed, or limited 
to, or more pronounced in, the lower and back parts of the lungs. The 
supervention of apoplexy, pneumonia, gangrene, and other states, will 
be recognized by their special indications. 

Treatment. — Very little can be done directly to relieve these me- 
chanical congestions. It is sometimes, in cardiac cases, useful to re- 
move blood by leeching, cupping, or venesection, or to act on the bowels 
or other emunctories. But, for the most part, all we can do is to treat 
the heart affection according to principles elsewhere laid down, and the 
febrile disorder according to the general indications which it presents. 



DROPSY. HYDROTHORAX. 

Causation and Morbid Anatomy. — (Edema constantly occurs as an 
incident of the inflammatory process. (Edema of the larynx, which is 
so often a cause of death, is almost without exception the result of in- 
flammation either of the larynx itself or of parts in its immediate neigh- 
borhood ; pneumonic consolidation of the lung ijrusually attended with 
more or less oedema of the lung-tissue surrounding the consolidated 
district; and pleurisy is very rarely indeed unaccompanied by serous 
effusion into the pleural cavity. Independently of inflammatory dropsy, 



DROPSY — HYDROTHORAX. 441 

however, which does not now concern us, there are other forms of dropsy, 
for the most part of mechanical origin, which are sufficiently important 
in their effects to call for a few remarks. Dropsy of the respiratory 
organs, like dropsy of other parts, may be due, equally with congestion, 
to certain forms of cardiac disease and other affections involving ob- 
struction of veins ; it may arise, also, in the course of renal disease, and 
occasionally originates in mere anaemia. 

1. (Edema of the larynx may undoubtedly occur in the course of 
renal disease and heart disease, and in those cases in which, from the 
presence of mediastinal tumors, the vena cava descendens, or the innom- 
inate veins are obstructed, and possibly may, even in the uncompli- 
cated state, cause dangerous symptoms and death. Generally, however, 
when serious symptoms arise, inflammation has become superadded to 
the dropsy ; and indeed the supervention of inflammation doubtless 
constitutes the chief danger of this limited dropsy. 

2. (Edema of the lungs is a frequent accompaniment of general ana- 
sarca, from whatever cause ; but it is especially frequent in the course 
of scarlatinal affection of the kidneys and other forms of Bright's dis- 
ease, and may occur in a high degree, even when there is little or no 
dropsy observable in other parts of the body. An oedematous lung is 
usually voluminous, heavy and pale, and on section large quantities of 
serous fluid mingled with air-bubbles drain away or may be squeezed 
out. It contains much less air proportionately to its bulk than natural, 
but is rarely quite devoid of air in any part. If the lung be at the 
same time congested, it combines the characters of congestion and 
oedema. In hypostatic congestion, which has been already described, 
there is usually such a combination. (Edema, like congestion, some- 
times results in a form of pneumonic consolidation, and not unfre- 
quently in a form of earn ifi cation or collapse. 

3. Pleural dropsy, or hydrothorax, occurs under the same conditions 
as oedema of the lungs, and indeed is very often associated with it in 
the sense of being complementary to it. That is to say, hydrothorax, 
which is a serious and frequent item of general dropsy (whether this 
be dependent on cardiac, renal, or pulmonary disease), and tends for 
the most part to arise whenever oedema of the lungs tends to arise, 
tends nevertheless mechanically to exclude this latter condition, and 
conversely. Thus, if there be much pulmonary oedema there is proba- 
bly little pleural effusion ; if much pleural effusion, little pulmonary 
oedema ; and if there be coincidence of pleural and pulmonary dropsy 
on the same side, the pulmonary dropsy is limited to that portion of 
lung which rises above the level of the pleural effusion, the rest of the 
lung probably being compressed and void both of air and of excess of 
fluid. And further, it often happens that, if one lung be bound down 
by adhesions, the other being free, there is pleural dropsy exclusively 
upon the one side, pulmonary oedema exclusively upon the other. Oc- 
casionally hydrothorax becomes so extreme that it distends the pleural 
cavity and causes complete collapse of the lung. 

Symptoms. — The symptoms of oedema of the larynx, so far as they 
are important, have already been fully considered. Those of oedema 
of the lungs are nearly identical with those of congestion of the same 



442 



DISEASES OF THE RESPIRATORY ORGANS. 



organs. There is gradually increasing difficulty of breathing with 
lividity of surface and other symptoms of defective aeration of the 
blood — symptoms which need not be rediscussed, but which, if not 
relieved, increase in severity until death takes place. There is usually 
also, sooner or later, more or less cough, with expectoration of thin 
serous fluid. The presence of oedema does not necessarily entail local 
indications ; the chest may be perfectly resonant, the breath sounds as 
nearly as possible healthy. Still, more or less crepitation may gen- 
erally be recognized, especially behind and below ; and with the pro- 
duction of consolidation the indications of that condition necessarily 
become developed. 

The general symptoms to which pleural dropsy gives rise are in the 
main those of pulmonary oedema. The local signs are those which 
have already been described as indicative of the presence of fluid in the 
pleural cavity. 

Treatment. — The treatment of dropsy of the larynx, lungs and 
pleurae, resolves itself into that of the diseases which give rise to it. 
We must refer, therefore, to observations made elsewhere upon the 
treatment of inflammations and tumors of these organs, and upon that 
of heart disease, bronchitis, and albuminuria. It may, however, be 
pointed out that when, even in advanced heart or kidney disease, the 
patient with dropsical accumulation within the pleura is suffering 
much from dyspnoea, great (even though it be merely temporary) relief 
may often be given by the performance of paracentesis. The removal 
of even a few ounces of fluid may be efficacious. In reference to this 
point it is worth while to remark that there is often much more fluid 
in a pleural cavity than might be suspected from a casual examination. 
For in determining its presence and amount, the patient is usually 
made to sit up in bed and bend his trunk forwards — a position which 
necessarily throws the fluid forwards and reduces the height of the level 
of dulness behind in relation to the landmarks which usually guide us. 



PULMONAEY COLLAPSE. ATELECTASIS. 

Causation and Morbid Anatomy. — Under a considerable variety of 
circumstances, more or less extensive portions of the lungs become void 
of air and shrink, assuming an appearance to which the term carnifica- 
tion has been commonly applied. 

1. The simplest form of this condition is that which is observed in 
a lung or part of a lung compressed by accumulation of fluid within 
the pleura. It is very much reduced in bulk, wrinkled and livid on 
the surface, uniformly smooth, dark, and flesh-like on section (the 
bronchial tubes and larger vessels being compressed equally with the 
vesicular texture), tough but flabby in consistence, heavier than water, 
and capable of being reinflated through the bronchial tubes which 
lead to it. 

2. A second form is that which is frequently observed post-mortem 



PULMONARY COLLAPSE. 



443 



in the lungs of patients dead of bronchitis, or of fevers, or of other 
affections in which, from debility, or from blocking up of some of the 
smaller bronchial tubes, respiration has been incompletely performed. 
Here the collapse does not, as a rule, involve any considerable continu- 
ous tract, but affects scattered groups of lobules, which are, however, 
usually most abundant and largest in the lower portions of the lungs. 
In such cases the lungs present considerable irregularity of surface — 
depressed, livid-looking polygonal patches alternating with elevated 
tracts of comparatively pale and crepitant tissue. On section the de- 
pressed arese are found to correspond to dark-colored, airless, smooth, 
tough, carnified patches, which extend to various depths into the sub- 
stance of the lung. In many cases a few such patches of collapse only 
are visible; in others the collective bulk of collapsed lung-tissue is very 
considerable. 

Very frequently, no doubt, the condition of the affected portions of 
lung is identical with that of lungs compressed by pleural effusion ; 
and in nearly all cases inflation may be readily performed. It must 
not be forgotten, however, that collapse not uncommonly takes place 
in lung-tissue which is already much congested or (Edematous, when, 
of course, the shrinking is less pronounced, and the tissue is more juicy 
and more easily lacerable than in the simpler forms of collapse. Nor 
must it be forgotten that in many cases, and more especially perhaps 
when the collapse is a complication of bronchitis, there is a tendency 
for it to pass into, or to be associated with, lobular pneumonia, and 
that then patches of apparently pure collapse may often be found asso- 
ciated with patches of distinct lobular pneumonia, and with others 
presenting gradations between these extremes. The main physical 
distinctions between lung-tissue consolidated from collapse and pneu- 
monic tissue, are, the shrunken condition, the smooth, homogeneous, 
shiny, reddish-black sectional surface, and the toughness of the former, 
the expanded, granular, lacerable, and, for the most part, pale-reddish 
or grayish marbled aspect of the latter. 

The explanation of the production of the form of collapse now under 
consideration is not far to seek. Dr. Gairdner's theory is simple, and 
has found general acceptance. According to it, the smaller tubes 
become more or less completely filled with mucus, which acts in each 
case as a valvular plug, preventing the passage of air beyond it, during 
inspiration, by becoming then more tightly wedged in the narrowing 
tube, but allowing the escape of air from the implicated air-cells during 
expiration by being then driven upwards into the wider portion of tube 
above. It is not quite clear, however, that mucus is generally capable 
of performing this twofold action, nor is it essential that it should so 
act in order that collapse should be produced. The simple but com- 
plete and prolonged obstruction of a small bronchus is amply sufficient 
to cause collapse of the portion of lung to which it leads — the obstruc- 
tion preventing both ingress and egress of atmospheric air, and the 
tissues beyond gradually absorbing the air which is retained within 
them. 

3. A third form of what may still conveniently be termed collapse 
is that which is commonly known by the name of atelectasis. This is 



444 



DISEASES OF THE RESPIRATORY ORGANS. 



really the persistence of the foetal condition of lung, the condition of 
the affected lung-tissue being little, if at all, distinguishable from that 
of ordinary collapse. 

Symptoms and Progress. — In discussing the morbid anatomy and 
symptoms of collapse, it is so usual to confound it with lobular pneu- 
monia (with which, indeed, it is frequently associated), that the result 
is less an account of collapse than of inflammation. Collapse is, for 
the most part, a mere consequence of other lesions, and gives rise to 
but few distinctive symptoms. Nevertheless, there are some cases, 
doubtless, in which its occurrence aggravates the patient's symptoms, 
and diminishes the chances of his recovery. This is more especially 
the case in the bronchial affections of young children, in hooping- 
cough, measles, and the like, for in children, owing to the yielding- 
ness of the thoracic walls, perfect inflation of the lungs under difficul- 
ties is often impossible, the flexible framework of the chest failing to 
respond to the efforts of the inspiratory muscles. The symptoms to 
which extensive collapse may be expected to give rise are in the main 
those which attend congestion and oedema, namely, gradually increas- 
ing dyspnoea, with the other consequences of defective aeration of the 
blood. We have already, in discussing the subject of bronchiectasis, 
adverted to the fact that collapsed lung-tissue, whether the collapse be 
due to congenital origin or pressure, or bronchial affection, may remain 
permanently solid, and pointed out that there is good reason to believe 
that it is in such conditions that bronchiectasis with globular dilata- 
tions not unfrequently takes its origin. It may also be added that 
extensive collapse of lung-tissue is necessarily associated with depres- 
sion and comparative immobility of the thoracic parietes in relation 
with the affected tracts, and that hence, in young children, there not 
unfrequently results permanent impairment of the form of the chest, 
the lower half usually becoming contracted in the horizontal plane, 
while the upper remains normally, or even becomes abnormally ex- 
panded. 

Treatment. — Pulmonary collapse, apart from the bronchial and other 
affections which attend it, and the permanent consequences which it 
sometimes entails, scarcely calls for special treatment. 



HEMORRHAGE. PULMONARY APOPLEXY. 
HAEMOPTYSIS. 

Causation and Morbid Anatomy. — Haemorrhage from the respiratory 
organs may be of two kinds : first, that in which the blood is yielded 
by some part of the air-passages, or by cavities in direct continuity 
with them ; and second, that in which it takes place primarily into the 
substance of the lungs. 

1. The former kind is due either to congestion, inflammation, ulcer- 
ation, or injury of some parts of the surfaces alluded to. It may occur 
in the course of simple or ulcerative inflammation of the larynx, trachea, 



HAEMORRHAGE. 



445 



or bronchial tubes. It may attend syphilitic, carcinomatous, or tuber- 
cular affections of the same parts. It may take place during the pro- 
cesses of detachment of the membranes of diphtheria or plastic bron- 
chitis, of the discharge of hydatids and of the opening of abscesses. It 
may be due also to the rupture of an aneurism into the trachea, bron- 
chial tubes, or pulmonary tissue. In all of these cases the haemorrhage 
takes place, either from numbers of minute vessels, or from one vessel 
of comparatively large size which has undergone ulceration or rupture. 

If in these cases the effused blood be small in quantity, it is usually 
mingled with the sputa in the form of spots or streaks. If it be more 
abundant, it becomes more generally diffused throughout their mass. 
When profuse it not unfrequently accumulates in the cavities or tubes 
which yield it, or finds its way by the effects of gravity or of the acts 
of inspiration into other tubes, and even into those of the opposite lung. 
Under the latter circumstances it is apt to coagulate and form solid 
casts of the channels in which it lies. It is said that blood effused from 
the bronchial or other passages may be sucked into the air-cells, and 
thus cause the condition termed pulmonary apoplexy. This we are not 
disposed to admit. 

2. The second variety of haemorrhage takes place into the air-cells 
and interalveolar texture of the lungs; and the effused blood tends 
partly to be expectorated, partly to accumulate in the tissues, producing 
the condition termed pulmonary apoplexy. This form of haemorrhage 
attends pneumonia, but is rarely excessive in this disease, or productive 
of apoplexy. Pulmonary apoplexy is much more common in lobular 
pneumonia and pyaemia. Its most frequent cause, however, is heart 
disease, attended with impediment to the passage of blood through the 
left cavities, or with extreme feebleness of circulation. Further, pul- 
monary apoplexy not unfrequently complicates Bright's disease in its 
advanced stages, embolism of the pulmonary artery, and those cases in 
which, whether from debility or other causes, there is a tendency to the 
formation of coagula in the vessels generally. 

Pulmonary apoplexy is indicated post mortem by the presence of 
patches of lung-tissue of various sizes, from that of a pulmonary lobule 
up to that of a hen's egg, or larger, which are for the most part dis- 
tinctly limited by the margins of the outermost of the affected lobules, 
are distended like pneumonic tissue, are of a dark, reddish-black color 
like colored clots which have not been exposed to the atmosphere, con- 
tain little or no air, yield a little sanious perhaps frothy serum on pres- 
sure, and are heavy, and more or less brittle or lacerable. The number 
of patches which may be present, and their sizes, are liable to great 
variety; they may occur in any region of either lung, but are most 
common towards the lower part. The presence of pulmonary apoplexy 
is usually associated with that of moulded adherent clots in the arterial 
branches leading to them, to the formation of which, indeed, there is 
reason to believe that they are often, if not always, due. Apoplectic 
clots undergo decolorization, as does blood effused into the subcutaneous 
tissues ; and if small may disappear, leaving behind them some granular 
brownish pigment only. Sometimes they soften and break down; and 
generally they induce inflammatory mischief in the lung-tissue which 



446 



DISEASES OF THE RESPIRATORY ORGANS. 



surrounds them and in the pleural surface upon which they abut. The 
surrounding inflammation is sometimes pretty extensive, and the blend- 
ing of the two morbid conditions may make it difficult to decide the 
relation between them, or to define their respective limits. 

3. Besides the above varieties of haemorrhage there are others de- 
pendent on constitutional disorders which may affect indifferently the 
parenchyma of the lungs, and the mucous membrane of the air-passages, 
or which are of uncertain origin. Such are the hemorrhage which at- 
tends purpura, that which takes place in some cases of typhus, small- 
pox, diphtheria, and similar diseases, that form which is said to occur 
vicariously of menstruation, and that due to diminished atmospheric 
pressure. 

Symptoms and Progress. — It is not usually a difficult matter to deter- 
mine whether blood voided by the mouth is derived from the respira- 
tory organs or not. The facts that it is expelled by coughing, and has 
a florid frothy character, the detection by auscultation of crepitation in 
one lung, or in part of a lung, and (if its source be apoplectic) the rec- 
ognition of dulness and of the other local indications of pulmonary con- 
solidation, will of course be important aids to diagnosis. Further, 
careful inquiry into the history of the patient, or examination of his 
thoracic organs will, in a very large proportion of cases, reveal the 
presence of organic pulmonary, cardiac, or arterial disease. At the 
same time we must not forget to look to the nose and fauces, in order 
to be sure that the blood is not yielded by those parts, and especially 
to determine, so far as may be, the condition of the oesophagus and 
stomach. Still it is quite possible to make mistakes in spite of the 
most anxious care; and it is important, therefore, to bear in mind the 
following considerations: first, haemorrhage may take place from the 
lungs, and yet no other evidence of thoracic disease be present; second, 
it may, especially if it be from the larger air-passages, be so sudden and 
profuse that the blood pours from the mouth without any effort at 
coughing, and even with more or less of the sensation and appearance 
of sickness; third, although the blood of haemoptysis is usually de- 
scribed as frothy and scarlet, when it escapes in large quantities its color 
may be that of blood in any other form of haemorrhage, and quite de- 
void of any peculiar amount of frothiness; and when it has lain in 
bronchial tubes or cavities, or has been derived from apoplectic effu- 
sions, it not unfrequently is dark-colored or almost black, or of a more 
or less dull chocolate or coffee-ground hue; fourth, in profuse pul- 
monary haemorrhage blood may be swallowed in considerable quan- 
tity and subsequently vomited or passed by stool, while, on the other 
hand, in haematemesis or epistaxis blood not unfrequently finds its way 
into the air-tubes, and becomes voided thence by coughing. When 
pulmonary haemorrhage is slight, as it is in bronchitis, pneumonia, and 
pulmonary apoplexy, the symptoms to which it gives rise are unim- 
portant; when, however, it is profuse, as it not unfrequently is in 
phthisis or carcinoma, or when an artery or vein is perforated or an 
aneurism ruptured, the symptoms and prospects are in the highest de- 
gree grave. In some cases the patient dies suddenly, either choked by 



PNEUMOTHORAX. 



447 



the violent outburst, or rendered syncopic from the loss of blood ; or 
he may sink from the effects of repeated hemorrhagic attacks. 

Treatment. — Many of the varieties of pulmonary haemorrhage which 
have been enumerated do not call for special treatment, and indeed, in 
the great majority of cases, the haemorrhage must be attacked through 
the disease to which it is due. This rule applies in great measure even 
to cardiac and to phthisical haemoptysis. When, however, the discharge 
is profuse, or threatens to become profuse, or in any way specially 
dangerous, its direct treatment becomes desirable. The patient should 
be kept exceedingly still, in the recumbent posture, and every means 
of quieting the circulation should be adopted ; no exertion, not even 
that of speaking, should be permitted ; he should be placed in a cool 
room, and be but little oppressed with bedclothes ; ice-bags may be 
applied to his chest; his food should be unstimulating, and but small 
in quantity; he should have cold drinks or ice to suck, and for medi- 
cinal remedies such as quiet the circulation or contract the smaller ar- 
teries, among which may especially be named lead, gallic acid, digitalis, 
and turpentine. Local or general bleeding may, in some cases, be jus- 
tifiable. The treatment of internal haemorrhages is, however, always 
eminently unsatisfactory. 



PNEUMOTHORAX. 

Causation and Morbid Anatomy. — The presence of air in the cavity 
of the pleura is almost invariably referable to the existence of some 
communication between that cavity and the external air. Thus, it 
may be due to a wound, such as is made in the operation of para- 
centesis or when the pleura is punctured in the carelessly performed 
operation of tracheotomy ; or to the opening into the pleura of an ab- 
scess already communicating with the exterior, such as an abscess in 
the parietes of the chest, an hydatid or other abscess of the liver, or one 
connected with carious vertebrae. Its most frequent causes, however, 
are the discharge of an empyema through the lungs or thoracic pa- 
rietes, and the opening of a tubercular or other pulmonary abscess into 
the pleural cavity. It is said to be caused sometimes by the rupture 
of emphysematous vesicles, sometimes by the decomposition of fluid 
and solid matters situated in the pleural cavity. 

Pneumothorax, even if it do not commence from empyema, is prob- 
ably always followed sooner or later by inflammatory effusion into the 
pleural cavity, or by the formation of pus therein. If it affect a cir- 
cumscribed portion only of the pleura there is little or nothing by 
which it can be distinguished practically or clinically from a large pul- 
monary vomica. The most striking cases are those in which a sudden 
and free communication takes place between the lung and a pleural 
cavity which had previously been healthy. Then air is admitted into 
the cavity with each inspiratory act, and, not being again expelled, 
accumulates at the expense of the lung, which undergoes gradual com- 
pression, of the mediastinum, which becomes displaced to the opposite 



448 



DISEASES OF THE RESPIRATORY ORGANS. 



side, of the diaphragm which is poshed downwards, and of the outer 
thoracic parietes, which become distended and immovable. The accu- 
mulation of air acts, indeed, mechanically in precisely the same way 
as the accumulation of .fluid. 

Symptoms and Progress. — The symptoms which mark the occurrence 
of pneumothorax are, for the most part, more or less sudden pain or 
uneasiness in the affected side, but especially the sudden supervention 
of severe and increasing dyspnoea. They are identical, as nearly as 
may be, with those of dropsical accumulation, but are much more rapid 
in their development. It need scarcely be added, however, that when 
the pneumothorax supervenes on empyema, or occurs within a limited 
space, no special symptoms may be developed. The physical signs 
have been already considered. They are mainly, in addition to disten- 
sion and immobility of the affected side, hyper-resonance on percussion, 
absence of respiratory murmur, with cavernous sounds and metallic 
tinkling, and diminution of vocal fremitus. The supervention of em- 
pyema, and the accumulation of fluid in the pleural cavity, lead to the 
production of additional physical phenomena which need not now be 
specified. 

Treatment. — The treatment of pneumothorax is in the main that of 
empyema. It may, however, be pointed out that, when intense dyspnoea 
rapidly comes on, it may be necessary to remove some of the accumulated 
air by paracentesis. 



PARALYTIC AFFECTIONS OF THE LARYNX. 

These affections are very various in their origin. They may be due 
to mere functional disturbance, as in the cases of hysterical patients i 
and of persons who lose the power of phonation from sudden fright or 
other mental disturbance ; to diphtheria ; to cerebral disease; to diseases 
involving the pneumogastric trunk, or that of either the superior or 
recurrent laryngeal nerves. It may be added that, from various causes, 
atrophy of one or more of the laryngeal muscles may take place. 

1. Paralysis of the recurrent laryngeal is usually referable to intra- 
thoracic disease or to tumors occupying the lower part of the neck, 
especially to aneurism and carcinoma, occasionally also to enlargement : 
of the thyroid body. It is an affection of tolerable frequency, and of 
great significance. When it is present the affected vocal cord remains 
motionless midway between the position of closure and that of com- 
plete patency, and the patient suffers from more or less complete 
aphonia. He is doubtless also liable to some degree of occasional 
dyspnoea. Indeed, it is generally held that one of the consequences of 
this form of paralysis is the occurrence from time to time of spasmodic 
attacks of intense difficulty of breathing and cough, which are apt to 
prove fatal. This, however, we believe to be an error, and are our- 
selves disposed to refer the dyspnoeal attacks which are so common in 
these cases to concurrent compression of the trachea, which is often 
induced by the same affection as induces the paralysis. 



PARALYTIC AFFECTIONS OF THE LARYNX. 



449 



2. Paralysis of the superior laryngeal is a rare affection. It may, 
however, result from the implication of the nerve in various morbid 
processes. This is the sensory nerve of the larynx, but supplies motor 
branches to the crico-thyroid muscles exclusively, and, in conjunction 
with the recurrent, to the arytenoid. The paralysis, therefore, involves 
more or less complete anaesthesia of the corresponding side, and in- 
ability of the corresponding cord to become stretched and tense. The 
symptoms indicative of this lesion are mainly, as Dr. Krishaber 
(quoted by Trousseau) remarks, hoarseness of voice, not absolute 
aphonia, but inability to utter high notes. Under laryngoscopy ex- 
amination, we should expect to see perfect execution of the movements 
of adduction and abduction, but failure of the vocal cord of the impli- 
cated side in the respect above pointed out. 

3. Complete unilateral paralysis, that is, palsy involving the pneu- 
mogastric trunk, and inducing loss of sensation as well as loss of 
motion on the affected side, is rarely if ever met with as an element of 
ordinary hemiplegia. It has, however, been observed in the case of 
tumors involving the nucleus of origin of the nerve in the medulla 
oblongata, and may be induced by the accidental division of the nerve 
in the neck, or by its implication in the progress of morbid growths, 
above the giving off of the laryngeal branches. In the case of disease 
of the medulla oblongata, it need scarcely be said that there must 
almost necessarily be involvement either of the hypoglossal or of some 
other neighboring nerve, or other paralytic phenomena, a combina- 
tion which would probably render the diagnosis comparatively easy. 
In the other cases, the existence of some lesion on the corresponding 
side of the neck would probably explain the nature of the laryngeal 
affection. The symptoms would be almost identical with those of 
paralysis of the recurrent laryngeal. Anaesthesia would probably be 
overlooked, unless attention were specially directed to the possibility 
of its presence. 

4. General paralysis, limited to the laryngeal muscles, is most fre- 
quently observed in hysterical patients, and may be readily induced in 
them by the occurrence of slight laryngeal inflammation, or under the 
influence of emotion. It may also be a sequela of acute laryngitis, of 
diphtheria, and of sudden fright, horror, or grief. In general paral- 
ysis the glottis remains open midway between the condition of closure 
and that of extreme patency, and the vocal cords lie immovable during 
the acts of respiration and attempts at vocalization, excepting in so far 
as they are disturbed by the current of air passing over them. The 
symptoms which it induces are complete aphonia and more or less 
breathlessness, which is apt to be paroxysmal. According to its cause, 
its advent will probably be sudden or gradual. Its duration, cura- 
bility, and liability to recur will also depend in great measure on its 
cause. As, however, it is almost invariably functional, a complete 
cure may generally be anticipated. 

5. In addition to the above, Dr. Mackenzie describes, as distinct 
varieties, paralysis of the adductor muscles and paralysis of the ab- 
ductor muscles, both of which may be bilateral or unilateral. In the 

29 



450 



DISEASES OF THE RESPIRATORY ORGANS. 



first case the glottis would be widely open, in the second closely shut ; 
in the last two the patency or closure would affect one side only. 

Treatment. — In the treatment of functional paralysis, the general 
health of the patient must be carefully considered, and as far as pos- 
sible improved. But local treatment is especially important. For 
this purpose, counter-irritation externally, and stimulating applications 
to the mucous membrane, are often useful. No local measures are so 
generally efficacious as the application of galvanism. This may- be 
effected by placing the electrodes on either side of the exterior of the 
larynx, or (with the aid of Dr. Mackenzie's or some other suitable 
apparatus) one within and one in contact with the skin over the situa- 
tion of the thyroid cartilage. The treatment of other forms of paraly- 
sis is involved in that of the conditions which give rise to them. 
They are often incurable. 



SPASM OF THE LARYNX AND TRACHEA. 

1. Larynx. — Spasm is chiefly known as causing contraction of the 
rima glottidis. It is rarely an independent affection, but is of common 
occurrence as a complication of other disorders. It is an essential 
element in hooping-cough, in spasmodic croup, and in the true epileptic 
seizure. It is readily induced by the inhalation of irritating vapors 
or by the entrance of solid or fluid matter into the larynx ; and it is 
frequently associated in a greater or less degree with inflammatory 
affections of the larynx. It may also be a phase of hysteria. Pro- 
longed spasmodic closure of the glottis, or laryngismus stridulus, a kind 
of epileptic convulsion, is occasionally fatal in young children. 

2. Trachea. — That spasmodic contraction of the trachea may take 
place is a physiological fact. How far it is a matter of auy importance 
is another question. We allude to it here, however, because we believe 
that when aneurismal or other tumors are compressing the trachea 
and inducing from time to time spasmodic attacks of dyspnoea, the 
immediate cause of the difficulty of breathing is not unfrequently spas- 
modic contraction of the muscular tissue of the compressed portion of 
the trachea, associated, it may be, with more or less hyperemia and 
accumulation of mucus. 

Treatment. — For the relief of laryngeal spasm the following measures 
may be serviceable; namely, the application of leeches, counter-irritants, 
or hot fomentations to the upper part of the chest in front, or to the 
neck; or the employment of hot baths, while cold water is dashed into 
the face ; and, for internal use, emetics, sedatives, and the inhalation of 
chloroform. Tracheotomy may be necessary. 



' ASTHMA. (Sjmsm of the Bronchial Tubes.) 

Definition. — The term asthma is often loosely applied to various 
forms of difficulty of breathing, and indeed, is very commonly em- 



ASTHMA . 



451 



ployed to designate the dyspnoea which attends ordinary chronic bron- 
chitis and emphysema, or cardiac disease, or that which is due to the 
pressure of tumors upon the trachea. We use the term here in its 
more correct and restricted sense to indicate a specific affection, charac- 
terized by the periodic recurrence of general contraction of the bronchial 
tubes and consequent dyspnoea. 

Causation. — Asthma is not unfrequently a distinctly inherited dis- 
ease, asthmatic parents begetting asthmatic children. It has been ob- 
served also occasionally to have some similar relation with epilepsy 
and other spasmodic nervous disorders. It affects males about twice 
as frequently as females. It may make its first appearance at any 
period of life, from birth up to extreme old age ; but most commonly 
commences during the first ten years of life. The first outbreak is 
often traceable to an attack of hooping-cough, measles, or bronchitis ; 
but, in a large proportion of cases, no such explanation of its origin 
can be discovered. When, however, patients have become asthmatic, 
paroxysms of dyspnoea may be excited by a wide range of conditions, 
which are unequally operative in different cases, and some of which are 
not improbably capable of originating the disease. Of these conditions, 
some appear to act directly, others indirectly upon the bronchial tubes. 
Of the former, Dr. Hyde Salter gives a long and interesting list, which 
includes the inhalation of smoke, dust, and pungent vapors, the smell of 
cats, dogs, horses, rabbits, and other animals, the scent of the rose, privet, 
and other flowers, the emanations from new-mown hay and powdered 
ipecacuanha, change of weather, the prevalence of particular winds, the 
presence of fog. But the most curious and mysterious of such causes 
is simple change of locality. Thus, some asthmatics suffer most in a 
dry atmosphere, some in a moist atmosphere, some at a high, some at 
a low elevation, some in inland localities, some by the seaside, some on 
one side of a street of which the opposite side is innocuous to them. 
But most find themselves better in London or other large towns than 
they are in the country, and, as a rule, a moist air is more suitable for 
them than a dry air, a low site better than an elevated site. Among 
the conditions which may be supposed to act indirectly are the inges- 
tion of certain articles of diet (which, however, differ so much for dif- 
ferent asthmatics that it would be useless to quote examples), distension 
of the stomach, constipation, disease of the brain, and violent emotions. 
It may be observed that Dr. Salter considers that when particular arti- 
cles of food cause asthmatic attacks, they act after absorption, and 
hence directly on the mucous membrane of the bronchial tubes. 

Symptoms and Progress. — The asthmatic paroxysm usually comes on 
without warning. In some cases, however, it is preceded for a shorter 
or longer time by premonitory symptoms, which are different for dif- 
ferent cases, but mostly uniform for each case. These are sometimes 
abnormal buoyancy of spirits, sometimes mental depression, sometimes 
drowsiness, but most frequently a slight degree of the asthmatic state 
manifesting itself by tendency to wheeze, constriction across the chest, 
sense of flatulence, alteration of carriage, and the like. Among the 
occasional earlier phenomena of asthma are a tendency to pass an 



452 



DISEASES OF THE RESPIRATORY ORGANS. 



abundance of pale limpid urine, and (as Dr. Salter points out) a pecu- 
liar troublesome itching under the chin, not relieved by scratching. 

The attack may come on at any hour, but is almost always uniform, 
or nearly so, as to the time of its supervention in each case. Some- 
times it occurs an hour or two after dinner, sometimes as soon as the 
patient lies down in bed, but in the great majority of cases between two 
and four o'clock in the morning, probably after the patient has had a 
comfortable sleep. There is no doubt, as Dr. Salter observes, that the 
forenoon is in every respect the most favorable time for asthmatics; 
their attacks least frequently commence then, and when on them are 
apt at that time to undergo some remission. 

The symptoms of the asthmatic paroxysm are mainly those of in- 
tense dyspnoea. The patient is probably roused from sleep with the 
symptoms full upon him, or, after a certain time of discomfort passed, 
between sleeping and waking, in battling with the augmenting dyspnoea, 
wake to the full consciousness of his condition. He is then compelled 
to rise from his bed — baring his chest and throwing aside everything 
that hampers his respiratory movements — in all the agony of impend- 
ing suffocation. The phenomena of the fully-developed paroxysm, are 
for the most part, as follows : The sense of suffocation is terrible ; the 
patient's whole energies are devoted to the performance of the respi- 
ratory acts ; his breathing is not rapid, often, indeed, is slower than 
natural, but it is effected with the most violent efforts ; his mouth is 
open, his nostrils dilated, his shoulders elevated, his head thrown back ; 
the respiratory muscles harden and stand out, and he places himself in 
some constrained position which gives them leverage — standing or sit- 
ting with his elbows resting on the table or some other elevated ledge, 
and his head buried in his hands, or grasping some unyielding object, 
generally above his head ; he places himself even in the depths of win- 
ter at the open window. The expression of his face is one of intense 
anxiety, the lines are strongly pronounced, his eyes are congested and 
protruding, his surface pale and ghastly, or livid ; copious perspirations 
break out upon his face, head, and trunk, while his arms and legs, and 
especially his hands and feet, become cold ; the pulse is rapid, small, 
feeble, and sometimes irregular. The dyspnoea is peculiar ; inspiration 
is comparatively short, expiration greatly prolonged, and both are at- 
tended with loud wheezing ; no interval exists between expiration and 
the following inspiration. The chest cavity is greatly expanded ; it is 
large and rounded from elevation of the ribs, elongated from depression 
of the diaphragm ; and this expansion is maintained even at the end of 
expiration — the fact being that the chest is abnormally distended with 
air, and that the powerful action of the respiratory muscles effects very 
little movement in the thoracic parietes, and consequently very little in- 
terchange of air. Dr. Salter points out, indeed, that this overdisten- 
sion of the chest begins to take place even before the appearance of 
manifest dyspnoeal symptoms, and that the descent of the diaphragm 
even at this early stage causes measurable enlargement of the upper 
region of the abdomen, which may easily be, and often is, mistaken for 
the effects of abdominal flatulence. On percussion the chest is proba- 
bly abnormally resonant, and the cardiac dulness is diminished in area 



ASTHMA. 



453 



or effaced. On auscultation there is usually total absence of respiratory 
murmur, but in its place general sibilant rhonchus in all its varieties. 
The patient speaks with difficulty, bringing his words out pantingly one 
by one. There is usually no cough, at all events none at the beginning 
of the attack. 

The duration of the paroxysm varies from a few minutes to several 
weeks — more frequently it is two or three days. In many instances it 
commences at the usual time and subsides in the course of the follow- 
ing day. In those cases in which the attack is much prolonged, it is 
usually made up of a series of shorter attacks, separated from one an- 
other by periods of more or less perfect remission. Its disappearance 
is attended with a gradual subsidence of the asthmatic phenomena, and 
with the supervention of cough. This is at first dry; but gradually 
crepitation replaces wheezing, and the cough is then attended with the 
expectoration of mucus in small transparent pearly pellets, and occa- 
sionally with sputa slightly streaked with blood. Frequently, and this 
is especially the case when the attacks have been of short duration, re- 
covery is rapid and complete. In other cases, however, the patient 
subsequently suffers for a longer or shorter time from some tightness 
at the chest and dyspnoea, with more or less cough and expectoration. 

Asthmatic attacks have not only a tendency to recur, but in a large 
number of cases to distinct periodicity of recurrence. Thus in some 
cases they come on weekly, monthly, yearly, or at other intervals which 
the patient's experience enables him to foretell. In most cases, how- 
ever, their recurrence is due to the more or less regular recurrence of 
those extrinsic causes which determine the attack; such, for example, 
as the assumption of the recumbent posture, variations in diet, change 
of residence, change of season, and the like. 

The prognosis of asthma is very uncertain. In many cases, espe- 
cially if it commence in infancy, it disappears during the period of 
adult life. When, however, it comes on at an advanced age it is prob- 
ably always permanent. Indeed, in a large proportion of cases, what- 
ever the time of its commencement, its duration is lifelong. But un- 
der these circumstances the affection usually undergoes some change of 
type with the advance of years. This change depends in a considerable 
degree on the slow T supervention of organic lesions. Thus, especially 
if the attacks be frequent and severe, the lungs after a time become 
emphysematous, and then the right side of the heart hypertrophous. 
The supervention of these organic changes is usually attended with 
diminution in the severity of the actual attacks of asthma, but with 
the development of permanent shortness of breath during the inter- 
vals between them, and of other symptoms of emphysema and chronic 
bronchitis. Further, asthmatic patients frequently acquire an almost 
characteristic physical conformation. They are as a rule, emaciated, 
with thin, furrowed cheeks, high shoulders, body bent forward, head 
thrown back, and misshapen chest — the upper part being dilated, the 
lower compressed, especially in the lateral direction. 

Dr. Salter divides asthma into idiopathic or primary, and sympto- 
matic or secondary. The former is the affection which we have en- 
deavored to describe. But symptoms identical in the main with those 



454 



DISEASES OF THE RESPIRATORY ORGANS. 



of asthma supervene secondarily on other affections, especially on dys- 
pepsia, on bronchitis, and on heart disease, and are termed by him pep- 
tic, bronchitic, and cardiac respectively. 

Pathology. — The extreme rarity with which death takes place in 
uncomplicated asthma renders the investigation of the pathology of the 
disease difficult. There is ample proof, however, that it is quite inde- 
pendent of organic lesion of the lungs, heart, or other important 
organs, and that it is therefore a so-called " functional " disease. In- 
deed, the observations of Drs. Gairdner and Salter establish, almost 
beyond the possibility of doubt, that the symptoms of the disease are 
essentially dependent on spasmodic contraction of the muscular tissue 
of the bronchial tubes, and consequent narrowing of their calibre. It 
is easy to see that such contraction is ample to explain not only the 
dyspnoeal symptoms, but the auscultatory peculiarities, the sudden 
accession and sudden subsidence of each attack, and also the organic 
changes which in some cases ensue. At the same time it may be worth 
while to notice that there is something in the persistence and singular 
periodicity of the disease, and in the fact of the frequent dependence of 
the paroxysm on a variety of apparently trivial conditions, to remind 
us of the skin affections known as urticaria evanida and factitious 
urticaria, and that urticaria-like swelling of the mucous membrane 
might equally explain the temporary contraction of the bronchial 
tubes. Under any view, however, the bronchial affection must be 
referred to the operation of the nervous system, either excited by re- 
flection from the bronchial surface or induced in some other way. 

Treatment. — In the treatment of the asthmatic paroxysm the patient 
should be placed in a cool, well-ventilated apartment, all ligatures and 
other impediments to respiration should be loosened, and he should be 
made to assume such a position as will enable him to use his respira- 
tory muscles to advantage. Further, any gastric or other derangement 
under which he may be suffering, or any condition which may be sup- 
posed to have induced or favored the attack should be at once, as far 
as possible, remedied or removed. Many drugs are more or less benefi- 
cial. Among these may be enumerated tartar emetic and ipecacuanha 
in emetic doses ; tobacco, given so as to produce its characteristic de- 
pressing effects, or smoked in the usual way ; lobelia inflata also so 
given, in large and frequently repeated doses, as to cause great de- 
pression ; datura stramonium or datura tatula, used either by inhala- 
tion or in the form of tincture or extract; belladonna, conium, hyos- 
cyamus, and opium (this latter, according to Dr. Salter, is injurious in 
uncomplicated asthma, benefiting those cases only in which there is 
associated bronchitis); alcohol, ether, strong coffee; nitre paper, burnt 
in the apartment; and chloroform. The effects of chloroform are mar- 
vellous, but unfortunately they are for the most part only temporary. 

The principles by which the general treatment of an asthmatic 
patient should be regulated are sufficiently simple : they consist in the 
avoidance of all the causes which in his case are known to induce an 
attack ; the selection of that locality for residence which experience has 
shown to be most suitable for his case ; and the maintenance of his 
general health by wholesome food, and by the adoption of habits and 



HAY ASTHMA. 



455 



of an employment compatible with health. If the patient have not 
yet learnt by experience what he can do and what he cannot do with 
impunity, the rules which we lay down for his guidance must be such 
as are in accordance with what we know of the general peculiarities of 
the disease. 



HAY ASTHMA. (Hay Fever.) 

' Definition. — This term has been applied to a peculiar catarrhal affec- 
tion coming on in this country during the months of May, June, and 
July, and commonly referred to the emanations from various flowering 
grasses, or from new-mown hay. A small number of persons only are 
susceptible, but these suffer annually at the season specified, unless 
they take precautions against the inhalation of the irritating influence, 
either by remaining indoors, or betaking themselves to some large 
town, or removing to the seaside, or taking a sea-voyage. The ten- 
dency to the affection seems hereditary. Attacks closely resembling 
those of hay asthma are produced in some persons by the smell of 
ipecacuanha or other vegetable effluvia, or by emanations from various 
animals, such as cats, rabbits, and dogs. 

Causation. — The precise cause of hay asthma has been a matter of 
discussion. Helmholtz, a few years ago, discovering, in the mucus 
discharged from the irritated mucous membrane, lowly vegetable or- 
ganisms, attributed the disease to their influence. Dr. Elliotson, 
many years since, suggested pollen as its cause. And Mr. Blackley, 
himself a sufferer, has recently published a work on hay asthma, in 
which, by a series of most careful researches, he appears to have proved 
the accuracy of Dr. Elliotson's suggestion. He comes to the conclu- 
sion that the effects of pollen are partly mechanical, partly chemical, 
and that it acts locally : if applied to the eye causing conjunctivitis, if 
to the nose coryza, if to the bronchial tubes by inhalation asthmatic 
symptoms. 

Symptoms and Progress. — The symptoms of hay asthma are in the 
main those of violent catarrh : itching, congestion and swelling of the 
conjunctivae and eyelids and watering of the eyes ; itching, congestion, 
tumefaction, and copious discharge from the nostrils, attended with 
much sneezing ; great irritation in the throat, fauces, and soft palate ; 
tightness at the chest, and dyspnoea, with cough and more or less ex- 
pectoration. The symptoms vary in their severity, and generally be- 
come aggravated towards the middle and end of June. In the first 
instance, or in mild attacks, the conjunctival and nasal mucous sur- 
faces alone may suffer. The symptoms are in all cases liable to more 
or less regular exacerbations. 

Treatment. — The most obvious and effectual method of treatment is 
the avoidance of the cause of the disease ; and, indeed, many sufferers 
have learnt by bitter experience entirely to shun the country and all 
proximity to grass fields and new hay during the dangerous season. 
For those who are compelled to expose themselves, the use of a respi- 



456 



DISEASES OF THE RESPIRATORY ORGANS. 



rator, made, as Mr. Blackley suggests, with six or eight folds of crape 
or a doable fold of cambric, will prove of considerable advantage. 
Helmholtz has recommended, and his recommendation appears to have 
been followed with more or less success, the washing out of the nostrils 
and throat with a weak solution of quinine, either by means of a 
pipette or the nose-douche. Other remedies which have been tried 
with reputed success are the tincture of nux vomica in ten minim 
closes, tincture of aconite, liquor arsenicalis, hydrocyanic acid, and the 
smoking of tobacco or stramonium. 



[AUTUMNAL CATARRH. 

Under this name Dr. Morrill Wyman, of Boston, has described a 
disease peculiar, so far as is known, to the United States, and having 
many points of resemblance to hay asthma, but differing from this in 
occurring towards the close, instead of at the beginning, of summer, 
and in the greater intensity of most of its symptoms, especially those 
presented by the eyes, nose, and throat. The cough is also apt to be 
more severe and paroxysmal, while attacks of asthma are more fre- 
quent. It is met with throughout the New England, Middle, and 
some of the Western States, with the exception of a part of the White 
Mountains country in New Hampshire, and of the elevated plateaux 
of the Alleghanies in New York and Pennsylvania, the inhabitants 
of which seem to enjoy an entire immunity from it. It apparently 
does not extend into the region lying west of the Mississippi, or into 
the Southern States ; nor is it found in the greater part of Canada. 
The attacks recur annually at about the same time, beginning generally 
on from the 18th to the 25th of August, and continuing until the oc- 
currence of the first severe frost, when they usually abruptly cease. In 
fact, such is the regularity of their appearance, that patients frequently 
know accurately the day, and it is said, in some cases even the hour, 
when to expect them. 

The sea-air does not afford the same relief as it does in hay asthma, 
and the sufferer, beyond being invigorated by it, and thus rendered 
better able to withstand the debilitating effects of the disease, is not ; 
benefited by a residence on the coast. Immediate improvement will 
often, on the other hand, follow his removal to one of the localities 
where the disease is not met with, and attacks may be wholly avoided 
by passing the summer in such a place. 

Causation. — The precise cause of this disease has never been posi- 
tively ascertained. There is good reason for believing that the attacks 
are produced, in some cases at least, by the irritating effects of the 
pollen of the Roman wormwood (Ambrosia artemisimjolia) upon the 
respiratory mucous membrane. Exacerbations are caused by the in- 
halation of dust or smoke, by exposure to a strong light, and by the 
smell of certain fruits and flowers. A hereditary predisposition to 
the disease may be traced in many of the cases. 



ANATOMICAL RELATIONS OF HEART. 



457 



Symptoms. — These so closely resemble those presented by hay asthma 
that it is unnecessary to give them in detail. 

Treatment. — Whenever the patient's means will allow he should 
at once seek relief, either by removal to a place in the United 
States where the disease does not occur, or by going to Europe. 
Patients rarely suffer while actually on the ocean ; a sea-voyage may 
therefore be prescribed in some cases with advantage. Among the 
remedies which have been employed with asserted advantage are quinia, 
arsenic, strychnia, bromide and iodide of potassium, and hydro- 
cyanic acid ; but medicines evidently exert little or no influence over 
the course of the disease.] 



IV.— DISEASES OF THE VASCULAR SYSTEM. 

The vascular system comprises the heart, arteries, veins, and capil- 
laries ; the lymphatic glands and vessels, together with certain ductless 
glands ; and the blood and its tributary fluids. Of all the parts here 
enumerated the heart, the centre and presiding genius of the system, is 
by far the most important, both physiologically and on pathological 
grounds ; and to the morbid conditions of the heart, therefore, we shall 
first direct attention. 

(1.) — DISEASES OF THE HEART. 
INTRODUCTORY REMARKS. 

Anatomy and Anatomical Relations of Heart. 

Dimensions of Heart. — The heart has been estimated somewhat 
roughly, yet not inaptly, to equal in size its owner's fist. It enlarges 
with the growth of the body until growth ceases, and then continues 
to enlarge, though slowly, during the remainder of life. Its average 
weight in the adult male varies between ten and eleven ounces ; in the 
adult female is about nine ounces. The capacities of its several cavi- 
ties are probably nearly equal ; the auricles, however, are believed to 
be somewhat less capacious than the ventricles, and the left cavities 
somewhat less capacious than the right. The ventricles of the adult 
heart have, each, a capacity which has been variously estimated at 
from two to five ounces. The mean capacity is probably three ounces. 
The thickness of the cardiac walls presents considerable differences : 
those of the right auricle measure on the average about a line ; those 
of the left auricle about a line and a half ; those of the right ventricle 
(at the base, where they are thickest) very nearly two lines ; and those 
of the left ventricle (midway between the base and apex, where their 



458 



DISEASES OF THE VASCULAR SYSTEM. 



thickness is greatest) rather more than five lines. Of the cardiac ori- 
fices the auriculo- ventricular are larger than the arterial, and those of 
the right side larger than those of the left side to which they respec- 
tively correspond. The following table gives Dr. Beaoock's circumfer- 
ential measurements : 

Males. Females. 
Inches. Inches. 

. . , , . , f Rischt, . . 4.74 4.56 
Auriculo- ventricular, < ' ^ g ^ 

. . . , f Pulmonic, . 3.55 3.49 

Arterial, \ Aortic, . . 3.15 3.02 



Relations of Heart to Pericardium. — The heart, which occupies the 
middle mediastinum, is contained within the fibrous pericardium, a 
somewhat conical bag, of which the base corresponds to a portion of 
the central tendon of the diaphragm, the apex to the ascending arch 
of the aorta, the pulmonary artery, and superior cava; with the parietes 
of which vessels, as also with those of the pulmonary veins and inferior 
cava, its fibrous tissue becomes blended. The serous pericardium, on 
the one hand, lines the fibrous pericardium in its whole extent; on the 
other hand, closely invests the heart, forms a tubular sheath around the 
trunk, of the pulmonary artery and the ascending aorta, furnishes in- 
complete investments to the proximal extremities of the pulmonary 
veins and vense cavse, and is reflected thence to become continuous with 
the parietal lamina. The pericardial cavity extends from the upper 
margin of the second costal cartilage above (at which point the ascend- 
ing arch ends), to the central tendon of the diaphragm below. 

Relations of Heart to Chest-walls and Surrounding Organs. — The 
heart occupies an oblique position. Its base, which includes the points 
of attachment of all the large arteries and veins, and is formed mainly 
by the auricles, is directed upwards, backwards, and to the right, and 
extends vertically from the fourth to the eighth dorsal vertebra. Its 
apex points in the opposite direction, namely, downwards, forwards, 
and to the left, and usually impinges between the fifth and sixth costal 
cartilages, a little internal to a line drawn vertically through the nipple. 
The position of the apex varies, however, a little in different healthy 
persons, and varies a little also with change of posture, and with the 
respiratory movements. If it beat in the fifth interspace during re- 
cumbency it probably beats against the sixth cartilage when the up- 
right position is assumed. The anterior aspect of the heart, which also 
faces upwards, is formed below and to the right by the right auricular 
appendage and right ventricle ; above and to the left by the left auricu- 
lar appendage and left ventricle. The greater part of this aspect, how- 
ever, is constituted by the right ventricle. The posterior aspect, which 
is also directed downwards and mainly rests on the diaphragm, consists 
of the two ventricles exclusively, the left ventricle forming by far its 
larger proportion. About two-thirds of the heart are situated to the 
left of the mesial plane of the body, the remainder to the right. 

The relations of the heart and great vessels to the surface of the chest 
are important. The outer margin of the left ventricle extends from 
the left second intercostal space (midway between the junctions of the 



ANATOMICAL RELATIONS OP HEART. 



459 



cartilages with the osseous ribs and with the sternum) outwards and 
downwards to the apex in the left fifth interspace. The outer margin 
of the right ventricle commences at the sternal end of the right fifth 
costal cartilage, and passes thence downwards and to the left to meet 
the former line in the apex. The left auricular appendage slightly over- 
laps the upper edge of the left ventricle, making its appearance in the 
lower part of the second intercostal space. The right auricular appen- 
dage extends from about the same level above (commencing, however, 
at the mesial line of the sternum) downwards to the point at which the 
margin of the right ventricle begins. Between these points it presents 
a semilunar form, the one limiting line taking a nearly straight course 
beneath the sternum, the other limiting line being convex, and extend- 
ing in the third and fourth interspaces, half-way from the sternum to 
the osseous ribs. 

Of the valves, the pulmonic is the highest and most superficial ; it 
is situated immediately to the left of the sternum — perhaps a little be- 
neath it — in the second interspace ; the aortic, which is deeper-seated 
than the pulmonic, and indeed partly overlapped by it, is subjacent to 
the junction of the left third cartilage with the sternum and to the ad- 
joining half of the sternum ; the tricuspid lies beneath the sternum, its 
centre midway between the sternal ends of the fourth costal cartilages; 
the mitral, which lies deepest of all the valves, is situated behind the 
pulmonic and aortic, and on a lower level than they, its central point 
probably corresponding to the left third interspace, a little external to 
the sternum. 

A small portion only of the heart is in actual contact with the an- 
terior walls of the chest, the remainder being separated from them by 
the thin anterior edges of the lungs. In ordinary tranquil inspiration 
the lungs almost meet in the mesial line of the sternum from above 
down to a point midway between the sternal ends of the fourth costal 
cartilages. From this point the edge of the right lung still continues 
vertically downwards, while that of the left retreats to the junction of 
the left fifth cartilage and rib, where it forms a notch just before its 
termination in the basal edge. A triangular interval is thus produced, 
situated wholly to the left of the mesial line of the sternum, bounded 
on either side by the edges of the lungs, and below by the diaphragm, 
to which the left lobe of the liver is immediately subjacent. In the 
outer angle of this space a small portion of the apex of the left ven- 
tricle becomes superficial, the rest of the triangle being occupied by the 
right ventricle. 

Laterally the heart is bounded by the lungs, from each of which it 
is separated by both pleura and pericardium ; posteriorly it is limited 
by the posterior mediastinum, with the roots of the lungs separating 
it above, and the oesophagus and thoracic aorta separating it in its whole 
extent from the vertebrae ; below it lies on the diaphragm, which di- 
vides it from the liver, and partly, to the extreme left, from the stomach. 
Above, it is continued into the large vessels, namely, the pulmonary 
artery, the aorta, and the vena cava. 

The ascending aortic arch, covered at first by the pulmonary arterial 
trunk, and then by the right auricular appendage, passes upwards and 



460 



DISEASES OF THE VASCULAR SYSTEM. 



to the right beneath the sternum, and extends for about a quarter of 
an inch beyond the edge of the sternum into the right second and first 
intercostal spaces. The superior cava extends half an inch farther in 
the same direction. The transverse arch corresponds as nearly as pos- 
sible to the lower half of the manubrium. The pulmonary artery passes 
between the two auricular appendages upwards, backwards, and to the 
left, and, having crossed the commencement of the aorta, lies to the 
left of that vessel, becoming superficial at the inner part of the left 
second interspace, just before it retreats under the aortic arch to divide 
into its two branches. 

Physiology of Heart. 

Action of Heart. — The function of the heart is to maintain the circu- 
lation of the blood in both the systemic and the pulmonary vessels. 
To effect this it undergoes a series of alternately active and passive 
movements, which are rhythmical and follow one another with greater or 
less rapidity. To commence with the ventricular contraction. The 
ventricles, having become distended with the blood transmitted to them 
from their respective auricles, suddenly and actively contract, propel- 
ling their contents into the aorta and pulmonary artery respectively, 
and causing at the same time the closure of the auriculo-ventricular 
valves. Whilst this contraction is in progress the auricles, which were 
contracted at the moment of its commencement, gradually dilate, and 
by the time the ventricles have become completely empty, have attained 
their full dimensions and are full of blood. The contracted ventricles 
now relax and in their turn expand, the arterial valves close, the auri- 
culo-ventricular valves open and allow of the flow of blood through the 
still dilated auricles into the ventricles. Soon the passively dilating 
ventricles become almost filled, when suddenly the hitherto torpid 
auricles contract, adding their contents to those of the ventricles which 
thus become distended. Immediately after the contraction of the j 
auricles, and indeed almost by a continuous peristaltic action, the con- 
traction of the ventricles takes place, and the cycle of events above 
described recurs. 

It is important to add, in the first place, that the actions of the two 1 
sides of the heart are, as nearly as possible, synchronous ; and in the 
second that the closure of the auriculo-ventricular valves takes place at 
the commencement of the cardiac systole, that of the arterial valves at I 
the commencement of the cardiac diastole. It must be added, too, that 
the force with which the ventricles act is always exactly equal to the 
resistance which they overcome ; that (other things being equal) con- 
traction of the arterioles calls for increase of cardiac exertion, their dila- 
tation for its diminution; and that (again other things being equal) 
increased quickness of the ventricular systole implies greatly augmented 
exercise of cardiac force, and conversely. 

The contraction of the heart is attended with distinct pulsation in 
the precordial region. The area over which this extends varies some- 1 
what with the form of the chest, and considerably with the varying 
degrees of thinness or plumpness of the thoracic parietes. Generally 



PULSE. 



461 



it is limited to the apex, where it is always most intense, and covers 
not more than a square inch of surface. A certain amount of epigastric 
pulsation, due to the movements of the right ventricle, is compatible 
with health. 

Sotmds of Heart. — The contraction and the dilatation of the ven- 
tricles are each attended with a characteristic sound, which marks the 
commencement of the act and is followed by a short interval of silence. 
These constitute respectively the first and second sounds of the heart. 
The first, or systolic sound varies in character in different persons ; it 
is, however, always deeper in tone and longer in duration than the 
other ; it is also more or less compact, beginning and ending with a cer- 
tain amount of abruptness. It is audible over the whole of the cardiac 
region, but is most pronounced over the apex of the left ventricle. The 
second, or diastolic sound is short, perhaps half the length of the first, 
sharp, and sometimes ringing. It is heard with greatest distinctness 
at the base of the heart, and more especially in the right second inter- 
space immediately adjoining the sternum. The loudness of the sounds 
and the extent of surface over which they are respectively audible are 
subject to great variety. 

Many causes have been assigned for the cardiac sounds. There is, 
however, now no doubt that the second sound is due to the sudden 
closure of the arterial valves which takes place at the commencement 
of the ventricular diastole ; and there is little doubt that the first sound 
is mainly attributable to the generally less sudden closure of the 
auriculo-ventricular valves which attends the commencement of the 
ventricular systole. But it is pretty certain that the first sound is 
reinforced by that due to the contraction of the muscular tissue of the 
cardiac walls. For the most part, as has been already pointed out, the 
two sides of the heart act in unison, and hence the two arterial valves 
usually concur in the production of the second sound, the two auriculo- 
ventricular in that of the first; but, inasmuch as the action of the left 
side of the heart is far more powerful than that of the right, the valves 
of that side take the chief share in the production of the cardiac sounds. 
It is owing to this fact that the second sound is usually loudest 
towards the base of the heart over the right half of the sternum, and 
that the first is usually most obvious where the left ventricle becomes 
superficial, namely, at the apex. When the sides do not act in perfect 
unison a more or less obvious reduplication of the cardiac sounds takes 
place. 

Pulse. — The intermittent injection of blood from the heart into the 
arteries produces the phenomenon known as the pulse. The beats of 
the pulse necessarily correspond in number and rhythm to the con- 
tractions of the cardiac ventricles ; and, like these latter, follow one 
another, for the most part, with remarkable regularity, although liable, 
in different persons, and under different circumstances, to present great 
variations as to rate and force, and always presenting slight relative 
increase of rate and force during inspiration and slight relative decrease 
during expiration. The character of the pulse, although mainly de- 
pending upon the action of the heart, is largely modified by the condi- 
tion of the arteries in which it occurs, and by the condition of the capil- 



462 



DISEASES OF THE VASCULAR SYSTEM. 



lary arteries and capillaries, and of the venous system beyond. Daring 
the whole period of the contraction of the left ventricle in systole, the 
contents of the ventricle are being propelled into the aorta ; and the force 
which is thus exerted within the arteries is expended partly in driving 
the blood already within the vessels onwards, partly in dilating the 
elastic walls of the arteries. The consequent arterial tension attains 
its maximum with more or less rapidity, and then diminishes before 
the systolic action is completed. As soon as, with the cessation of the 
systole, the propulsion of blood into the aorta ceases, the distended ar- 
teries contract upon the blood within them, still propelling it onwards, 
but with gradually diminishing force, until they have attained their 
former calibre or until their contraction is interrupted by the next 
cardiac systole. The period here adverted to corresponds to the ven- 
tricular diastole. If the pulse presented no other elements than those 
immediately due to the phenomena which have been considered, namely, 
the systolic distension of the artery, on the one hand, and its diastolic 
collapse on the other, the sphygmographic trace of the pulse would have 
some such form as that represented in Fig. 1. There would be a more 

FUf.7. 



z_ 

or less sudden rise, presenting a rounded summit, the highest point of 
which would correspond to the moment of highest arterial tension; and 
this would be followed by a more or less gradual fall. But for the 
most part the sphygmographic tracing displays other elements be- 
sides these. In the first place the line of ascent is usually prolonged 
vertically upwards and then suddenly falls, forming a very acute angle 
before it merges in the convex summit above indicated; and in the 
second place the line of diastolic collapse is for the most part inter- 
rupted at its commencement by a more or less distinct rise and fre- 
quently after a short interval by a further and less distinctly marked 
wave, or it may be by a diminishing series of waves. The typically 
complete tracing would thus present not less than four successive waves, 
of which at least two would correspond to the systole of the heart, and 
at least two to the diastole. The first of these waves, which is known 
as the primary or 'percussion wave, is generally attributed, not to any 
actual addition to the quantity of blood which the artery presenting it 
already contains, but to the impulse which is supposed to be transmitted 
along that blood by the shock of the commencing systole; and is sup- 
posed to precede by a scarcely appreciable interval the secondary or 
tidal wave which follows it. Dr. Galabin, however, shows that this 
explanation is incorrect, and "that the percussion and tidal waves form 
in the artery but one wave, and are only separated by the sphygmo- 
graph. Owing," he says, "to the inertia of the long lever it is carried 
up a little too high, and w T hen in falling it meets the true arterial wave 




PULSE. 



463 



it is again tossed up, and thus forms the tidal wave." The third, or 
the dicrotic wave, has, like the first, been variously explained. It has 
been attributed by many to the shock of the sudden closure of the aortic 
valves, an opinion in which Dr. Galabin concurs ; and again to the recoil 





1/ \> 


c 


1 




e 


f 





a, Primary or percussion wave; b, secondary or tidal wave; c, dicrotic wave; d, fourth wave; e, 
aortic notch ; e,f, duration of cardiac systole ; /, g, duration of cardiac diastole. 

The dotted line represents the tracing which would be drawn if the instrument followed the move- 
ment of the artery with perfect accuracy. 

Copied, with slight modification, from Dr. Galabin's diagram. — Thesis for the Degree of M. I)., Can- 
tab., 1873. 

of the hitherto distended arteries. But the cause is probably that which 
Dr. Sanderson assigns for it. He points out that as the wave due to the 
injection of the ventricular contents into the aorta takes a certain time 
to reach the capillary arteries, and as hence the period of greatest 
movement in the latter vessels must take place distinctly later than 
that in the aorta, so the subsidence of this wave and the period of com- 
parative rest which marks the end of systole and the whole of diastole 
is likewise delayed in transmission to the peripheral vessels; and that 
consequently there is a moment at which, while the blood is almost 
stagnant in the aorta, it is still flowing rapidly through the minuter 
vessels, and a later moment in which the blood in the capillaries be- 
comes also comparatively quiescent. But this arrest in the capil- 
laries, accompanied as it is by the contraction of the elastic arterial coat 
upon the diminished contents of the vessels, produces a virtual disten- 
sion and a sudden increase of pressure throughout the arterial system. 
The dicrotic wave is the expression of this arterial tension. The fourth 
wave has probably, as Dr. Galabin considers, the same relation to the 
dicrotic wave as the tidal to the percussion w T ave. 

Let us now briefly consider the significance in the order of their oc- 
currence of the more important of the several factors of the pulse- 
tracing which have been enumerated. The initial rise will necessarily 
be largely determined as to its amplitude by the suddenness and vio- 
lence of the cardiac systole; but will obviously be also influenced more 
or less considerably by the condition of the arteries, flaccidity aiding 
it, tension, on the other hand, opposing it. The presence of the tidal 
wave as a distinct event mainly depends upon the duration of the ten- 
sion of the arteries due to the ventricular systole. If the tension be of 
short duration the percussion wave falls rapidly and continuously until 
its fall is arrested by the dicrotic rise ; if it be long sustained then the 
second rise becomes developed, varying in its form according to the 
condition of the artery. The breadth of the combined summits of these 



464 



DISEASES OF THE VASCULAK SYSTEM. 



two curves is, therefore, a measure of the duration of the tension here 
adverted to ; the breadth of their bases as determined by a horizontal 
line drawn from the commencement of the systolic rise to the end of 
the systolic fall, is a measure of the duration of the cardiac systole ; 
and the lowest point of the notch which separates the tidal from the 
dicrotic wave indicates the moment of closure of the aortic valve. The 
third rise (the dicrotic wave) may be regarded as a measure of the com- 
pleteness of the check which the systolic wave experiences in the smaller 
vessels during the diastolic period, and is indicative, therefore, either 
of comparative feebleness of the heart's action or of high tension of 
the venous relatively to that of the arterial system. The duration of 
the diastolic period is measured by the horizontal line which may be 
drawn from the aortic notch to the commencement of the next systolic 
ascent. 

The character of the pulse varies in health, not only in different 
individuals, but in the same person at different times and under differ- 
ent circumstances. It may he frequent or infrequent, conditions which 
may be recognized as well by the finger and the watch as by any more 
complicated machinery. It may be long or short. These terms apply 
not to the whole interval between the commencement of one pulsation 
and that of the pulsation which next follows (for in that case they 
would be synonymous with "infrequent" and "frequent" respectively) 
but to the duration of the systolic wave. These qualities may be 
roughly recognized by the finger, but are demonstrated with accuracy 
by the sphygmographic tracing only. It should be noted here that 
when a pulse becomes increased in frequency, this increase is due 
mainly to curtailment of the diastolic period. It may be large or small. 
These terms are employed somewhat loosely ; the former should perhaps 
be used of that state in which a considerable volume of blood is pro- 
pelled into the arteries at each systole, and the latter of the converse 
condition. We are apt, however, to term that also a large pulse which 
occurs in dilated arteries, such as those of elderly persons, and that a 
small pulse in wmich the arteries are simply somewhat contracted. 
These different forms of largeness and different forms of smallness are 
often combined, and are indicated respectively in the sphygmographic 
trace by relative amplitude of the systolic waves. The pulse may be 
strong or weak, or in other words hard or soft. The former resists 
compression by the finger, the latter is easily obliterated by it. The 
best test, however, of strength of pulse is again the sphygmograph, 
by means of which the amount of pressure necessary to procure oblit- 
eration can be estimated with some degree of accuracy. It may be 
added that when there is high arterial tension it becomes necessary to 
use considerable pressure in order thoroughly to develop the character- 
istic tracing. 

Pathology of Heart. 

The heart and structures associated with it may, like all other organs, 
become the seat of inflammatory or other processes, which will then pro- 
duce the local and general symptoms which commonly belong to them. 
But the heart is an instrument of extreme delicacy, and is liable, under 



MECHANICAL AND STRUCTURAL DERANGEMENTS. 



465 



the influence of the processes here referred to, and under various other 
conditions, to have its mechanism more or less seriously deranged. 
These derangements, which may be structural or functional, or both 
combined, produce various local and various remote or general conse- 
quences which are the characteristic symptoms or sequela? of heart dis- 
ease. We propose to consider these briefly, apart from the intimate 
nature of the pathological lesions which produce them, and apart also 
from the special symptoms due to the specific characters of these lesions. 

1. Mechanical and Structural Derangements of Heart. 

The local lesions which interfere with the healthy action of the heart 
may, first, be situated external to the organ ; or, second, involve the 
muscular walls ; or, third, be connected with the valves; or, fourth, be 
situated within the cardiac cavities. It may of course happen that two 
or more of these lesions are associated. 

1. Affections External to the Heart. — Simple displacement of the 
heart is met with under many different circumstances. Occasionally, 
in company with the other viscera of the chest and abdomen, it is 
found transposed. Ascites or abdominal tumors may displace its apex 
upwards and to the left ; aortic aneurisms, and other tumors of the 
upper part of the chest or of the posterior mediastinum, may cause it 
to descend. Serous or other effusions into either pleura commonly 
push it over towards the opposite side ; while the contraction of the 
lung and side which so often follows the absorption of pleuritic fluid 
tends to attract it more and more towards the affected side. It may 
be observed that the displacements which result from the last two con- 
ditions are always much more noticeable when they take place towards 
the right than when they take place towards the left side ; in disten- 
sion of the left pleura it is not uncommon to find the heart beating 
wholly between the right nipple and right edge of the sternum. In 
spinal curvature, also, the position of the heart is often much modified, 
being then greatly determined by the relative sizes of the two halves 
of the chest and by the degree and form of the curvature ; sometimes 
it lies wholly to the right of the sternum, sometimes beneath it. Occa- 
sionally, when the patient is markedly pigeon-breasted, the heart oc- 
cupies the whole of the space which lies between the two nipples. The 
most remarkable displacements of the heart, however, are those which 
result from the growth of intrathoracic tumors. In these cases the 
apex of the organ has been detected beating in the right axilla. 

In reference to displacements, it is important to recollect that the 
base of the heart is comparatively firmly fixed above and posteriorly ; 
and that, although no doubt the parts contained within the posterior 
mediastinum and the base of the heart which is incorporated with 
them may be, and often are to a greater or less extent, displaced, it is 
that portion of the heart which lies free in the pericardium that is 
chiefly apt to suffer in this respect, and is often the only part so affected 
— the free or ventricular portion of the organ moving at its base as on 
a pivot. 

It is remarkable how greatly the heart may be displaced without im- 

30 



466 



DISEASES OF THE VASCULAR SYSTEM. 



pairment of function. Not unfrequently, however, more or less palpi- 
tation results ; and occasionally, if the displacement be permanent, 
hypertrophy and dilatation occur, and murmurs may be developed at 
one or other of the valvular orifices. 

Affections of the pericardium are much more important causes of 
cardiac disturbance than those just considered. They act mainly by 
compressing the heart and thus interfering with the efficient perform- 
ance of its duties. The affections here specially adverted to are such 
as are attended with effusion of fluid and those in which fibrous and 
other forms of solid material become accumulated. The effusion may 
be merely dropsical, or it may be inflammatory and associated with the 
formation of false membrane, or it may be purulent, or hemorrhagic. 

When fluid is poured forth into the cavity, it gradually distends it, 
enlarging it in all its dimensions, but chiefly in those situations in 
which the walls are least resistant. The cavity becomes rounded and 
at the same time elongated, especially in the upward direction along 
the ascending arch and the pulmonary artery ; and moreover by its 
distension it displaces the diaphragm downwards, and the lungs later- 
ally. At the same time the heart is necessarily carried with the por- 
tion of the parietal pericardium to which it is united backwards and 
consequently away from the anterior thoracic walls. The quantity of 
fluid which accumulates within the pericardium is sometimes enormous. 
Two and even three quarts have been met with. The larger quantities 
are generally the result of chronic disease, which allows of the gradual 
distension of the pericardial cavity to a much greater extent than is 
possible in acute cases. 

2. Affections of the Muscular Walls. — The muscular walls of the j 
heart are liable to many changes. Among these we may enumerate 
simple hypertrophy and simple atrophy. Hypertrophy, however, \ 
always takes place in response to some increased work which the heart 
is called upon to perform, is in general compensatory, and (apart from 
other associated cardiac defects) prevents rather than promotes cardiac 
embarrassment. Simple atrophy, again, almost invariably occurs in 
the course of chronic wasting disease, and in some sort of proportion | 
with the concurrent atrophy of the rest of the organism ; and hence 
the dwindled heart still remains sufficiently strong to perform the 
offices required of it, and as a rule gives rise to no untoward symp- 
toms. In many cases, however, the muscular tissue becomes enfeebled 
disproportionately to the rest of the frame, sometimes from mere di- 
latation and thinning, sometimes from fatty or other forms of degen- 
eration, sometimes from inflammation, sometimes from syphilitic for- 
mations, sometimes from sarcomatous or other such infiltrating growths. 

3. Affections of the Valves. — By far the most serious derangements 
on the whole are those connected with organic disease of the various 
valves. It is obvious that valvular defects may be of two kinds ; they 
may be obstructive, that is of a nature to impede the direct flow of 
blood through the valvular openings ; or they may be such as to admit 
of regurgitation, that is, the closure of the valves may be imperfect 
and reflux of blood may hence be permitted into the cavities behind 
them. The affections which produce these valvular lesions are very 



MECHANICAL AND STRUCTURAL DERANGEMENTS. 467 



various. We may here advert to the fact that the mitral valve, and 
still more the tricuspid, occasionally even in health admit of regurgi- 
tation from the ventricles into the auricles when the ventricles are 
overdistended with blood. In a large proportion of cases the lesions 
are due to inflammatory changes, namely, infiltration and thickening 
of the tissues of the valves, the formation of beaded or warty masses 
upon their surfaces, and consequent adhesion, ulceration, or laceration. 
In many cases, again, the valvular affection is consequent upon athero- 
matous and calcareous degeneration of the several structures connected 
with the valves. Occasionally it is the result of accidental violence, 
and occasionally of congenital malformation. Further incompetence 
is sometimes due to dilatation of the valvular orifices, a condition 
which is apt to go along with dilatation of the ventricles, and to affect 
mainly the auriculo-ventricular apertures. In these cases incompetence 
may be aggravated by comparative shortness of the carncce columnce, 
or chordce tendinece. We will briefly discuss the principal defects which 
the several valves are apt to present. 

Obstructive aortic valve disease may be due to the following causes : 
(a) adhesion of the several segments to one another — as a congenital 
defect it is not uncommon to find two contiguous cusps blended as far 
as their corpora Arantii, the coalesced sides forming a more or less 
obvious vertical franum which divides the upper aspect of the com- 
pound organ into two halves; more rarely the three valves are thus 
blended, and when the blending is pretty complete they form between 
them a conical funnel with a narrow orifice in the apex which is 
directed upwards: (b) the accumulation of inflammatory granulations: 
and (c) atheromatous or calcareous changes. These latter are often 
attended with great thickening and at the same time great rigidity of 
the valves, the orifice becoming in some cases converted into a mere 
chink. 

Regurgitant aortic valve disease depends (a) on contraction and puck- 
ering of the free edges of the valves, in consequence of which they fail 
to meet ; (b) on ulcerative destruction or contraction of the valves at 
their angles, which allows the intermediate free edges to form pendu- 
lous or everted flaps ; and (c) on rupture or actual perforation of the 
curtains. We do not of course refer here to the fenestra so com- 
monly observed in the lunulas, which, as is well known, do not in any 
degree impair the efficiency of the valves. 

Obstructive disease of the mitral valve may depend (a) on cohesion of 
the edges of the curtains ; this is often congenital, the valve then pre- 
senting a more or less funnel-like character, with its apex pointing 
towards the ventricle, and formed by a narrow, buttonhole-like slit; 
in most cases of this kind the valve is somewhat thickened and the 
chorda? tendinesB are short and thick, and sometimes the smaller 
branches, which radiate into the valves, become more or less com- 
pletely blended with them and with one another ; in cases of inflam- 
mation and of degenerative change there is a similar tendency towards 
the production of the various lesions here enumerated; (6) on inflam- 
mation which causes thickening and at the same time granular excres- 
cences ; and (c) on atheromatous and calcareous changes. 



468 



DISEASES OF THE VASCULAR SYSTEM. 



Regurgitant mitral disease may depend (a) on mere contraction* of 
the free edges of the cusps ; (b) on shortening or rupture of the chordae 
tendinese ; and (c) on perforation of the valves. 

The morbid conditions to which the valves on the right side are 
liable are identical with those which involve the corresponding valves 
on the left side. The pulmonic and tricuspid valves are, however, 
comparatively rarely the seat of other than congenital disease. 

4. Affections of the Contents. — Coagulation of blood in the heart's 
cavities not unfrequently takes place during life, more especially during 
the period in which a patient is moribund, when it must be regarded 
as a normal accompaniment of the process of dying. Older clots are 
also occasionally met with, such as the adherent rounded softening 
clots, or so-called " polypoid concretions," and the laminated clots 
which are also common in sacculated aneurisms. The causes of these 
different varieties of coagula, their anatomical peculiarities, and their 
effects, will be discussed at length under the head of thrombosis and 
embolism. 

2. Functional Derangements. 

1. Motor derangements reveal themselves by undue feebleness or 
force, frequency or infrequency of action, by intermission or irregularity, 
or by sudden arrest of action from spasm or paralysis. Several of 
these are only exaggerations of conditions which are compatible with 
health. Feebleness of the heart's action attends most wasting diseases 
and the later period of many febrile and other acute affections. It is 
common also in mitral valve disease, and in some other morbid condi- 
tions of the heart. It is characterized by weakness of apex beat, 
diminution in intensity of the cardiac sounds, especially of the first, 
which may be absolutely abolished ; by weakness of the pulse, which 
is undulatory, thready, or markedly dicrotous, and may be imper- 
ceptible at the wrist, even while maintaining a distinctly dicrotous 
character in the larger arteries ; and, lastly, by a great tendency to 
variation in the rate of the pulsations under the slightest disturbing 
influences. Augmentation of force of the cardiac action tends to take 
place whenever any impediment to the flow of blood occurs either at 
the aortic orifice or in the course of the arteries, in the capillary ves- 
sels or in the venous system. It is therefore common in aortic valve 
disease, in the presence of rigid arteries, and in Bright's disease. It 
may also occur in inflammatory disorders, during muscular exertion, 
and under the influence of nervous excitement. The indications of 
this condition are violence and extension of the cardiac impulse, which 
is often prolonged and heaving, and may be felt in the back and may 
even shake the entire body ; loudness of the cardiac sounds, and hard- 
ness of pulse. Increased frequency of pulsation occurs under many 
various conditions; such as nervous excitement, debility, febrile dis- 
ease, and so on. The individual pulsations may be weak or strong, 
and the characters presented by the cardiac movements, its sounds, and 
the arterial pulse will correspond. Diminution in the frequency of 
pulsation is common in convalescence from acute disorders. It is met 
with also in some cerebral affections and in some cases of cardiac dis- 



EFFECTS OF CARDIAC DERANGEMENTS. 



409 



ease. The pulsations of the heart may mount up to 200 or even 260 
in the minute, and they may fall to 20 or even 12. The term palpi- 
tation is commonly used of those conditions in which the pulsations of 
the heart, or of the arteries, or of both, under the influence of nervous 
excitement, are painfully evident to the patient himself; the beats are 
frequent, sudden, and violent, and the pulse often attended with 
marked dicrotism. Irregularity of the cardiac rhythm is occasionally 
observed in gout and indigestion, but is most frequently associated 
with various forms of heart disease, and more especially with affections 
of the mitral valve. It is manifested by inequality of the successive 
pulsations, both as regards their force and fulness and the length of 
the interval which elapses between them. Intermission of action is a 
form of irregularity which is mostly purely functional ; it is common 
in dyspepsia, and is occasionally a constitutional peculiarity of the 
patient. In intermission the general rhythm of the heart's action is 
not impaired, but at regular or irregular intervals a pulsation is 
dropped, as it were. At the wrist it is wholly absent; on listening to 
the heart, however, the intermission is represented by an abortive 
throb, followed by a pulsation of greater intensity than those which 
follow next. Occasionally such abortive strokes may occur alternately 
with effective ones, and the pulsations at the wrist be half as numerous 
as the cardiac strokes. Sudden arrest of the heart's action, and con- 
sequent death, may be caused by shock or syncope, and is not un- 
common in certain forms of heart disease. 

2. Abnormal sensations are frequently associated with cardiac affec- 
tions. In palpitation the pulsations of the heart and often of the larger 
arteries are distinctly felt and complained of by the patient. When 
intermission takes place the sufferer generally experiences a kind of 
throb or tumble in the region of the heart, or a choking sensation 
which may be attended with momentary faintness. A feeling of op- 
pression at the chest, or fulness, or aching, is not uncommon. And 
sometimes the pain may be intense, prolonged, and indeed unbearable, 
extending over the whole cardiac region, or limited to some definite 
part of it, and often radiating thence to various parts of the trunk and 
to the extremities. 

3. Effects of Cardiac Derangements on the Walls and Cavities 
of the Heart. 

The effect of continued overexertion of the heart, as of all other 
muscles, is hypertrophy. Its muscular tissue becomes increased in 
quantity and its walls consequently in thickness ; and at the same 
time its cavities almost invariably undergo more or less dilatation. 
The hypertrophic walls are, as a rule, denser than those of the healthy 
heart, and often present, in addition to augmentation of muscular 
fibres, augmentation of connective and other tissues. Nevertheless it 
not unfrequently happens that, as disease advances, the hypertrophied 
muscle becomes enfeebled in consequence of fatty or other degenerative 
changes. The amount of hypertrophy may, however, with this reser- 
vation, be taken as the measure of the increased labor which the heart 



470 



DISEASES OF THE VASCULAR SYSTEM. 



has been called upon to perform. Although dilatation in some degree 
probably always accompanies hypertrophy, and owes its origin to the 
same cause, it must be regarded, not as an evidence of strength, but as 
the result of weakness — of the yieldingness of the heart's walls to the 
increased internal pressure to which they are subjected, and hence, 
although accompanying hypertrophy, as antagonistic to it. It will 
thus be readily understood that, other things being equal, a heart in- 
trinsically weak will become dilated more than hypertrophied under 
the stimulus of overexertion ; that a heart intrinsically strong will, 
under similar circumstances, become hypertrophied rather than dilated. 
It must be added that dilatation, which is sometimes the primary or- 
ganic change in hearts which are simply feeble, not only impairs effi- 
ciency, but actually furnishes an incentive to cardiac exertion and 
overgrowth. In the great majority of cases the dilatation of the car- 
diac cavities is uniform ; occasionally, however, the thinner portions of 
the walls, and occasionally softened or weakened portions, yield dis- 
proportionately. 

The above remarks are general. We will now apply them. When- 
ever any persistent obstacle exists to the escape of blood through the 
aortic orifice in consequence of valvular disease, or along the arteries, 
or through the capillary network beyond, the left ventricle gradually 
becomes hypertrophied, and in a greater or less degree dilated as well. 
For a time this hypertrophic change is almost purely compensatory ; 
the increased force of the heart's contractions almost exactly counter- 
balances the effects of the obstacle ; the heart acts regularly, the ven- 
tricle empties itself completely at each contraction, the mitral valve 
acts perfectly, and the auricle experiences no difficulty in the trans- 
mission of its contents into the ventricle. So far all the morbid 
changes are confined to the left ventricle ; but after a longer or shorter 
period disproportion arises between the hypertrophy of the ventricle 
on the one hand, and its dilatation and the impediment to be overcome 
on the other ; the ventricle fails to act efficiently, probably does not 
wholly expel its contents at each beat, and the auricle consequently 
now begins to experience some difficulty in getting rid of its contents, 
and in its turn becomes dilated and hypertrophic. The same sequence 
of phenomena follows that virtual impediment to the aortic circulation 
which results from aortic valve incompetence. In this case, however, 
dilatation doubtless precedes hypertrophy, and the auricle probably 
becomes stimulated to overexertion at a comparatively early period. 

Whenever disease, whether it be obstructive or regurgitant, exists at 
the mitral orifice blood tends to accumulate in the left auricle, while 
increased force is needed for its propulsion thence; the cavity, there- 
fore, of the auricle becomes enlarged, and its walls thickened. But 
inasmuch as no valves exist at the orifices of the pulmonary veins, or 
in any part of the course of the pulmonary vessels, the augmented 
pressure of blood which commences within the auricle speedily spreads 
backwards throughout the entire pulmonary system. And hence arise 
impediment to the escape of blood from the right ventricle and conse- 
quent hypertrophy and dilatation of it. 

Disease affecting the pulmonic orifice, equally with increased blood- 



EFFECTS OF CARDIAC DERANGEMENTS. 



471 



pressure within the pulmonary artery, necessarily causes dilatation and 
hypertrophy of the right ventricle, which are presently followed by 
similar affections of the right auricle. 

Disease of the tricuspid orifice provokes like changes in the right 
auricle, and in connection therewith accumulation of blood in the sys- 
temic veins and dilatation of these vessels, to be gradually followed by 
similar conditions in the systemic capillaries and arteries and conse- 
quent obstruction to the escape of blood from the aortic orifice. 

It will be understood from the foregoing observations that when dis- 
ease (actual or virtual) exists at any valvular orifice, first the cavity 
behind it becomes hypertrophied and dilated, and subsequently the same 
conditions gradually involve cavity after cavity in the backward direc- 
tion, until possibly every one may become thus affected in a greater or 
less degree; and, further, that in the extension of these conditions from 
the left auricle to the right ventricle, or from the right auricle to the 
left ventricle, the pulmonic or systemic vascular system, as the case 
may be, necessarily suffers from undue accumulation and pressure of 
blood within it. 

The form which the heart assumes is greatly, and often very charac- 
teristically, modified, by the hypertrophic and other changes which it 
undergoes. In general hypertrophy and dilatation, such as are met 
with in chronic albuminuria, the shape of the heart is altogether un- 
changed. When aortic valve disease alone is present, the left ventricle 
is alone, or chiefly, enlarged ; and not only does its left edge extend 
further than usual to the left, so that more of the ventricle is exposed 
when we look at the organ in situ, but the apex projects far beyond 
that of the right ventricle. In mitral valve disease the left auricle be- 
comes enlarged, but the right ventricle very soon indeed shares in the 
enlargement; the left ventricle, on the other hand, is relatively small; 
generally it either remains stationary or dwindles, or if it enlarges its 
enlargement is inconsiderable; the heart consequently acquires a nearly 
globular form, and the right apex either comes to share equally with 
the left in constituting the heart's apex, or exclusively constitutes it. 
The same form of heart results from disease of the pulmonic orifice, or 
from chronic pulmonary disease ; but here the left auricle remains 
small. 

It must not be forgotten that a constantly palpitating heart becomes 
dilated and hypertrophied in consequence of its palpitation; and that 
not only temporary violent muscular effort, but also habitual sustained 
exertion, induces similar organic changes. Dr. Allbutt, who has in- 
vestigated this subject with close attention, believes that in such cases 
the hypertrophy and dilatation commence on the right side of the 
heart, and are thence propagated to the opposite side. It should be 
added that simple dilatation not unfrequently causes valvular incom- 
petence. 

Effects of Derangements of the Heart on the General Organism. 

The disturbance to the circulation which results from cardiac affec- 
tions cannot long continue without causing more or less serious disturb- 



472 



DISEASES OF THE VASCULAR SYSTEM. 



ance of other organs or groups of organs. In connection with the 
pulmonary stasis which attends mitral disease and other equivalent 
conditions, we observe congestion and oedema of the lungs, effusion of 
blood into the pulmonary tissue (pulmonary apoplexy), thrombosis of 
the pulmonary arteries, which is generally associated with and is prob- 
ably the cause of pulmonary apoplexy, tendency to inflammation, and 
all the symptoms — lividity, dyspnoea, and the like — which flow from 
such affections. In connection with systemic stasis there arise general 
dilatation of veins and capillaries, with congestion and tendency to 
haemorrhage ; anasarca, especially of dependent parts ; dropsy of serous 
cavities, and thrombosis ; moreover, the liver becomes congested and 
indurated, and assumes the well-known nutmeg character, and jaundice 
and other consequences of hepatic disorder ensue ; the kidneys get con- 
gested and indurated, and the urine scanty and albuminous ; and not 
unfrequeutly the gastro-intestinal tract undergoes functional disturb- 
ance, or becomes the seat of hemorrhagic effusion or organic lesions. 
p The central nervous system is especially apt to suffer ; from insufficient 
supply of blood to it follow attacks of syncope and epileptiform con- 
vulsions ; from hyperemia, drowsiness, and coma; besides which, head- 
ache, vertigo, and delirium are not uncommon ; and occasionally cere- 
bral apoplexy from laceration of vessels ensues, with all the ordinary 
symptoms indicative of that condition. We must not forget to allude 
here to the occasional consequences of the detachment of cardiac vege- 
tations, or particles of atheromatous or calcareous detritus, or of the 
escape of the contents of softened clots, namely, embolic obstructions of 
the arteries of various organs, but more especially of those of the brain, 
spleen, kidneys, liver, and lungs. 

The Diagnostic Indications of Cardiac Derangements. 

So far as physical diagnosis (that is, diagnosis based on the local de- 
velopment of acoustic, visual, and tactile phenomena) is concerned, the 
most important points to which we have to attend in the investigation 
of cardiac diseases, are : first, alterations in the form of the precordial 
region; second, alterations in the form and extent of the area over which 
dulness on percussion extends ; third, changes of resistance ; fourth, the 
situation, extent, and character of the cardiac pulsation, together with 
the presence or absence of vibration or tremor ; and, fifth, the presence 
of abnormal sounds. 

1 . Alterations in the form of the precordial region can generally be 
easily recognized by mere inspection. Frequently, when the heart is 
enlarged, and still more frequently when there is effusion into the peri- 
cardium, this region becomes distinctly prominent over a greater or 
less extent of surface. This change is much more readily produced in 
the child than in the adult. It may be added that when much peri- 
cardial effusion is present the intercostal depressions of the implicated 
region are apt to be smoothed away and effaced; sometimes, indeed, they 
actually project. When the bulging is considerable, its degree may be 
to some extent determined, partly by comparing by actual measurement 
the horizontal circumference of the two halves of the chest, partly by 



DIAGNOSIS OF CARDIAC DERANGEMENTS. 



473 



comparing, on the two sides, the relative distances between any corre- 
sponding pairs of points, as, for example, those between the nipples and 
the mid-line of the sternum, the width of corresponding intercostal 
spaces, and the like. 

2. Alterations in the area of cardiac dulness must be ascertained 
either by the use of the pleximeter and hammer, or by the ordinary 
mode of percussion. The dulness over the precordial region, like 
other forms of dulness, varies in different individuals (partly according 
to the quantity of fat or flesh present in the thoracic parietes, and partly 
according to the condition of the bony framework) from the almost im- 
perceptible sound produced by percussing the thigh, or the sharpish 
click which may be elicited from the patella or the forehead, to the 
comparatively dull thud which is yielded by the sternum. Even in 
the same individual, the dulness obtained over the sternum is markedly 
different from that obtained over the costal cartilages; and indeed the 
presence of dulness must be determined less by the absolute sound 
which is elicited than by comparing it with the sounds yielded by per- 
cussion of neighboring parts, and more especially of corresponding 
parts on the opposite side of the chest. Increased area of dulness may 
depend either on pericardial effusion, on hypertrophy or distension 
of the heart, on the presence of tumors, or on the retraction of the free 
edges of the lungs. On the other hand, extension of dulness in cardiac 
disease may be counteracted or annulled by the presence of pulmonary 
emphysema. 

3. Increased resistance is, for the most part, due to the presence of 
thick, dense pericardial adhesions, or of solid formations of other kinds. 
The change may be detected by mere pressure of the hand, but is most 
strikingly revealed by the entire absence of that yieldingness which is 
generally so obvious on percussion of the thoracic parietes. 

4. Pulsation and Thrill. — The apex of the heart changes its position 
under various circumstances. In hypertrophy, it is found beating below 
and external to its normal position. In pericarditis with effusion the 
apex is somewhat elevated, and this elevation is said to be maintained 
to some extent even after adhesion has taken place. In some cases the 
cardiac pulsation extends over a large surface. This is especially ob- 
servable in cases of hypertrophy; and in hypertrophy of the right 
ventricle this pulsation becomes strikingly obvious in the epigastrium. 
Extension of pulsation is also manifested in cases of pericardial effu- 
sion ; but the pulsation is then mainly due to the undulations which 
the movements of the heart excite in the fluid which surrounds it, and 
are not strictly synchronous with the cardiac movements. Again, the 
cardiac pulsation varies in its character. In hypertrophy it is pro- 
longed and heaving, in palpitation it is short and violent, and in some 
cases of associated hypertrophy and dilatation, a distinct impulse or 
jog attends the diastole as well as the systole. In the last case, too, 
it often happens that the systolic impulse of the apex is accompanied 
by an obvious subsidence of the rest of the precordial region. But, 
besides these, certain adventitious movements of the thoracic parietes 
are sometimes present in cardiac diseases, such as tremor or fremitus — 
trembling or vibratile movements, which are occasionally likened to 



474 



DISEASES OF THE VASCULAR SYSTEM. 



the purring of a cat. They are sometimes present in pericarditis, but 
still more obviously in certain forms of valve-disease, more especially 
regurgitant aortic and direct mitral. 

5. The production of abnormal sounds by the movements of the heart, 
or of the blood which passes through it, may be recognized either by 
the ear applied to the cardiac region, or by the use of the stethoscope. 
These sounds are usually termed " murmurs," or " bruits." The peri- 
cardial murmur, or friction sound, is produced by the attrition of the 
roughened surface of the heart against the roughened surface of the 
parietal pericardium. It varies in character, being sometimes a uniform 
to-and-fro sound, like that produced by rubbing two pieces of paper 
together; sometimes a more or less uniform crackling, or rumbling, 
or creaking; sometimes a series of irregular jogs, which are generally 
more numerous than the sounds of the heart, and rarely synchronous 
with them, -and depend on the fact that the equable movement of the 
opposed surfaces on one another is interfered with by the obstacle 
which their roughness or stickiness interposes. Pericardial sounds, 
especially if of limited extent, are not always distinguishable from en- 
docardial murmurs ; they rarely, however, present much intensity, are 
probably never musical, and are scarcely perceptible except immedi- 
ately over the part at which they are developed. Endocardial murmurs 
may be produced at any one of the four valvular orifices of the heart, 
either during the systole of the ventricles or during their diastole. 
Thus, at either the aortic or the pulmonic orifice a murmur may be 
developed while the blood is flowing from the ventricle into the artery ; 
or, on the other hand, during the period of diastole, in consequence of 
the reflux of blood from the artery into the ventricle. The former 
murmurs are known as systolic or direct, the latter as diastolic or re- 
gurgitant, of the respective arterial orifices. And thus, also, at the 
mitral or the tricuspid orifice a murmur may arise either during the 
systole of the ventricle in consequence of regurgitation of blood from 
the ventricle into the auricle, or during the diastole of the ventricle 
while the blood is pursuing its normal course from the auricle into it. 
The former murmurs are respectively systolic mitral and systolic tri- 
cuspid, and are at the same time regurgitant ; the latter are diastolic or 
direct. Cardiac murmurs either replace the normal sounds of the heart 
or are superadded to them. They are necessarily loudest at the points 
at which they are developed ; but in consequence of the intervention of 
cardiac structures which are not implicated, or of the free edges of the 
lungs, they are not necessarily loudest at those portions of the chest 
surface which are nearest to these points. Again, they are carried, as 
might be supposed, by the blood-stream, and are hence louder in the 
course of that stream than in the opposite direction. Endocardial 
murmurs present a wide range of character, dependent on differences 
of intensity, quality, and pitch. As to intensity, they may be so soft 
as to be barely detectable, or so loud as to be distinctly audible by the 
unaided ear at a short distance from the pericardial region. As to 
quality, they may resemble a simple whiff, a whispered vowel, a whis- 
pered r, or a prolonged s ; they may be harsh and rough, or grating, 
or they may have a more or less distinctly musical character. And, , 



DIAGNOSIS OF CARDIAC DERANGEMENTS. 



475 



lastly, the musical note may vary in pitch from bass to treble, from a 
deep hum or buzz to a whistle. They are often compared to sounds 
with which we are familiar, such as blowing, cooing, sawing, rasping, 
and the like ; and, apart from such special qualities, are usually dis- 
tinguishable from the normal heart-sounds by their greater prolonga- 
tion, and by the fact of their comparatively gradual subsidence. En- 
docardial murmurs are the result of molecular vibrations produced in 
the blood as it traverses one or other of the cardiac orifices. Molecular 
vibration, it need scarcely be said, is always present, but it is only 
rendered sufficiently intense to evolve sound either when the blood is 
driven with unnatural velocity through one of the orifices (as sometimes 
happens at the healthy aortic or pulmonic orifice in anaemia or palpita- 
tion), or when it meets in its course with some impediment, or encoun- 
ters some roughness or projection, or some pendulous vibratile body. 
It is not always possible, nor is it important, to determine the condi- 
tions on which the different qualities of murmurs depend. It may, 
however, be remarked that roughness or hoarseness of sound implies 
for the most part roughness or irregularity (however produced) at the 
orifice at which it is developed, and that musical quality may be 
determined by extreme narrowness of orifice, and especially by such 
conditions of the edges of an orifice as permit them to perform regular 
vibrations. The roughest and most grating murmurs probably are the 
consequence of partial detachment of valves, or of rupture of chordae 
tendinese, which allows the implicated valve to flutter loosely in the 
blood-current. The most distinctly musical sounds are chiefly observed 
in murmurs due to regurgitation, as might be supposed from the com- 
bination of narrowness of orifice and of vibratile edges which is then 
commonly present. There can be no doubt that the quality of cardiac 
murmurs is often very distinctly modified by the resonance of the blood- 
containing ventricular cavities ; that, in fact, murmurs not otherwise 
musical are thus rendered more or less musical, and that musical mur- 
murs have some of their harmonics developed by this means with dis- 
proportionate power. It is obvious that such modifications must mainly 
occur while the ventricles are filling or full, and hence affect murmurs 
developed during the ventricular diastole. It is probable that the deep 
tone of so-called " presystolic " murmurs is in some measure due to 
this circumstance; and that the different qualities of the same murmur, 
as heard over the aortic orifice where it is created, and at the apex 
whither it is conveyed, are similarly explicable. 

Venous Murmurs. — It may be added here that venous murmurs, 
consisting of a continuous humming or buzzing, whistling or hissing, 
are not uncommon in the larger veins when they are partially ob- 
structed, and especially in anaemic patients. They may generally be 
best detected in the neck, particularly on the right side. 

The Diagnosis, Prognosis, and Treatment of Cardiac Derangements. 

1 . Pericardial effusion is indicated locally by bulging of the precor- 
dial region, with more or less distinct effacement of the corresponding 
intercostal spaces ; by diffused undulatory pulsation and elevation of 



476 



DISEASES OF THE VASCULAR SYSTEM. 



the cardiac apex ; by extension of dulness, which assumes a triangular 
form, and extending mainly upwards, may reach from the clavicle 
above to the diaphragm below, and be bounded to the left by an 
oblique line passing from the junction of the left first rib and cartilage 
downwards and outwards through or beyond the left nipple, and on 
the right by a line running, for the most part vertically, somewhere 
between the right nipple and the median line of the sternum. The 
effect of pericardial effusion on the heart is to embarrass its action, to 
cause it to beat quickly, weakly, and irregularly, and to deaden its 
sounds. The pulse becomes correspondingly affected. The patient 
suffers from shortness of breath, pain or difficulty in breathing, and 
palpitation, and, not unfrequently, owing to interference with neigh- 
boring organs, complains also of fulness in the throat and difficulty in 
swallowing. 

Pericardial adhesion, w T hich is commonly the consequence of peri- 
carditis, cannot always be recognized by either local or general signs. 
If it occur simply in patches, or if, being general, it be caused by a 
delicate adventitious lamina, there will probably be nothing whatever 
to indicate its presence. If, however, the accumulation of fibroid 
material be thick or dense, there will necessarily remain more or less 
permanent increase of the area of cardiac dulness, more or less dis- 
turbance of the heart's action, and more or less tendency to the devel- 
opment of the ordinary symptoms of chronic heart disease. The local 
indications of adherent pericardium are mainly permanent extension 
of precordial dulness, elevation of the apex of the heart and displace- 
ment to the left, and it is said recession of the thoracic walls over the 
apex of the heart at the time of systole in place of the normal pro- 
trusion. 

Our prognosis of pericardial effusion must largely depend upon what 
we know of its cause, and its causes, we need scarcely say, are numer- 
ous. We may point out, however, that when effusion takes place 
rapidly, as it does when an aneurism or the heart itself ruptures into 
the pericardium, the effects are remarkable, the cavity becomes rapidly 
distended, and the heart presently ceases to act, mainly, if not entirely, 
from its inability to contend against the compressing force to which 
it is subjected. When effusion of fluid takes place slowly, however, 
the parietal pericardium undergoes gradual distension, and enormous 
accumulation may then ensue, with only moderate embarrassment of 
the heart's action. The consequences of adhesion of the pericardium 
are various; in many cases no influence whatever is exerted upon the 
muscular parietes, or on the action of the heart, and the patient con- 
tinues in good health ; in many cases, however, especially if the adhe- 
sions be abundant or thick, the action of the heart becomes more or 
less seriously embarrassed, and this embarrassment involves in some 
cases hypertrophy and dilatation, in some atrophy of the organ, and in 
either case aggravation of the patient's symptoms. 

The treatment of pericardial effusion will be best considered with 
the various morbid conditions on which it depends ; that of embarrass- 
ment of the heart from adherent pericardium resolves itself mainly into 



DIAGNOSIS OF CARDIAC DERANGEMENTS.. 477 



that of enfeeblement of the cardiac walls, which will be referred to 
further on. 

2. 'Hypertrophy of the heart (as has been already shown) is probably 
always associated with more or less dilatation, always originates in 
overwork, and is, in a very large proportion of cases, developed, in 
obedience to its exciting cause, more largely on one side of the heart 
than the other. From these statements it will be seen that the pres- 
ence of hypertrophy and its distribution may generally be predicted 
from a knowledge of the existence of one of the recognized causes of 
hypertrophy, and further, it may be gathered that cardiac hypertrophy 
rarely, if ever, exists in an uncomplicated form. The presence of 
hypertrophy is generally indicated by extension of precordial dulness, 
prominence of the precordial region, and powerful, heaving, diffused, 
cardiac impulse. If the hypertrophy be general, or involve mainly 
the left side, the apex of the heart becomes displaced downwards and 
outwards, and may be found as low as the seventh interspace or eighth 
rib, and an inch or two outside the nipple ; moreover, the pulse be- 
comes hard, and the arteries become tense, and manifest a tendency to 
degenerate and yield. If hypertrophy affect the right side only, or in 
chief part, epigastric pulsation becomes a prominent feature, and the 
apex beat is diffused and ill-defined. In this case the pulsation of the 
systemic arteries is not necessarily affected, the tension is limited to 
the pulmonary vessels, and it is these which are, after a time, apt to 
become dilated and to degenerate. The cardiac sounds, and more espe- 
cially the first, are said to be duller than natural in simple hypertro- 
phy, but to become much increased in loudness when dilatation is asso- 
ciated with hypertrophy. 

Prognosis. — Hypertrophy is in most cases compensatory, and there- 
fore rather a benefit than an injury to the patient; dangers, however, 
follow in its train, the more important of which are dilatation of cavi- 
ties, incompetence of valves, and degenerative changes in the muscular 
tissue of the heart itself and in the arterial system — all of them indi- 
cations and sources of failing strength. 

Treatment. — If these statements be correct, the treatment of cardiac 
hypertrophy becomes a matter of great simplicity. We can only remove 
hypertrophy by removing or obviating the lesion which has provoked 
it, and by maintaining the circulation in an equable and quiet condi- 
tion, by forbidding mental and bodily excitement or overexertion, and 
by careful attention to the healthy maintenance of the functions of the 
body generally. It is, however, of the highest importance to delay or 
prevent the supervention of that enfeebled condition of heart in which 
hypertrophy so commonly and disastrously ends, and this must be 
effected by promoting the general health of the patient, for which pur- 
pose iron and other tonics, change of air, and nourishing diet are often 
necessary. 

3. Feebleness of the heart is a consequence of numerous different kinds 
of lesions, such as dilatation, and degenerative changes in its walls, and 
is a late result of most organic affections of the organ. It is attended 
with more or less feebleness of the cardiac sounds and beats, and a cor- 
responding condition of the pulse, which is sometimes increased in fre- 



478 



DISEASES OF THE VASCULAR SYSTEM. 



quency, sometimes slower than normal, and often irregular. The patient 
has, moreover, difficulty of breathing and palpitation, especially under 
excitement or on exertion, probably cardiac neuralgia, liability to faint, 
and venous congestion, with tendency to rapid supervention of dropsy 
and the other usual consequences of heart disease. The symptoms are 
scarcely distinguishable from those of incompetence of the mitral 
valve, with which lesion, indeed, debility of the heart, is often asso- 
ciated. Enfeeblement of the heart is one of the recognized causes of 
sudden death. 

Prognosis. — Whenever a diseased heart becomes also enfeebled, the 
symptoms from which the patient suffers are greatly aggravated. En- 
feeblement of the heart, indeed, whenever it occurs apart from, and out 
of proportion to, enfeeblement of the general system, is always of grave 
import. 

The treatment which is indicated differs little, if at all, from that 
needed in the later stages of valvular, and more especially mitral 
valvular disease, a subject which will be presently considered. 

4. Valvular Lesions, a. Aortic Valve Disease. — Obstructive disease is 
characterized by the presence of a murmur, which commences with the 
commencement of the heart's systole, and is continued onwards during 
the systolic silence. It is usually loudest over the right half of the 
sternum at the level of the third cartilage or third interspace, is very 
distinct over the ascending arch, and sometimes even in the back along 
the descending arch and upper part of the thoracic aorta; and it 
diminishes in force as it is traced from the base of the heart to the 
apex. The extent of its diffusion depends largely upon its loudness 
or pitch; when feeble it may be audible only over the valve and 
ascending arch. It is synchronous with the carotid pulse and cardiac 
impulse. The diagnosis of aortic valve disease is aided by the hyper- 
trophic condition of the heart which attends it, and by the prolonged 
elevation of the systolic element of the pulse. In aortic regurgitation, 
the murmur which is produced commences with the second sound of 
the heart, which in some cases it entirely replaces, and is generally 
much prolonged, sometimes up to the very commencement of systole. 
It is usually most distinctly audible in the neighborhood of the aortic 
orifice, and is carried thence downwards by the refluent stream towards 
the apex, often more particularly along the sternum, diminishing, how- 
ever, in intensity in its passage, and sometimes undergoing some 
change of quality. Occasionally it is most distinct over the lower 
part of the sternum. It is generally rapidly lost along the ascending 
arch. If feeble, it may be detectable only over the valve and the ad- 
joining portion of the ventricle. It occurs alternately with the carotid 
pulsations and the cardiac impulses. Its diagnosis is assisted by the 
fact of the heart being dilated and hypertrophied and by the character 
of the pulse. The latter has usually a peculiar jerky quality, which 
is due to a combination of sudden violence of the systolic wave with 
an equally sudden collapse — the latter being so sudden and extreme 
that the dicrotous rise is almost or entirely suppressed. This peculiar 
variety of pulse is sometimes termed Corrigan's, sometimes the " water- 
hammer" pulse. 



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DIAGNOSIS OF CARDIAC DERANGEMENTS. 



479 



b. Pulmonic Valve Disease. — A systolic murmur produced at the 
pulmonic orifice is heard loudest over the left edge of the sternum, or 
about the level of the third costal cartilage. It is heard also over the 
trunk of the pulmonary artery, namely, at or about the left edge of the 
sternum, as high as the upper border of the second cartilage. But it 
is inaudible, or nearly so, to the right of the sternum and along the 

! ascending aortic arch, and fades away as it is traced downwards over 
the right ventricle. Organic murmurs at this orifice are rare, except- 
ing as the result of congenital disease. The most common by far are 
ansemic. Regurgitant murmurs from defect of the pulmonic valve are 
of extreme rarity. They would naturally be best heard over the dis- 
eased valve, and thence downwards towards the right apex. 

c. Mitral Valve Disease. — Of all murmurs the systolic mitral, or that 
due to regurgitation through the mitral orifice, is the most common. 
It attends the systole of the heart, and like the direct aortic therefore, 
is synchronous with the carotid pulse. It is usually heard most dis- 
tinctly, not immediately over the valve, but over that part of the left 
ventricle which is most superficially placed, namely, the apex. Some- 
times it is audible in this position only, but, if intense, .may often be 
heard over the whole of the precordial region. In this latter case it 
generally diminishes in loudness from the apex to the base, but occa- 
sionally increases again in force over the situation of the aortic orifice, 
or at that part of the left ventricle which, next to the apex, approaches 
nearest to the surface of the thorax. A systolic regurgitant murmur is 
carried back with the refluent blood into the left auricle; and, partly 
on this account, and partly because of the situation of the left ventricle 
to the left and back of the heart, it is generally very audible in the 
axilla and at the back of the chest on the level of the heart — a fact of 
great importance in the recognition of this murmur. Direct mitral 
murmurs, which are due to obstructive disease of the mitral valve, 
occur during the diastolic period, and until of late years have generally 
been overlooked or misinterpreted. They are often absent because, 
although obstructive disease is not uncommon, the force with which 
the blood passes from the auricle into the ventricle is generally insuf- 
ficient to generate a murmur. It is well known, however, to physiolo- 
gists that during the earlier period of the ventricular diastole the blood is 
flowing almost passively through the auricle into the ventricle, and 
that it is only at the last, just before the ventricle itself contracts, that 
the auricle contracts and propels its blood with vigor. It is at this 
moment, therefore, that a murmur is most likely to be developed. It 
need scarcely be added that, when the auricle has become, as it soon 
does, dilated and hypertrophied, and the time occupied in discharging 
its contents more or less protracted, the murmur is likely to be ren- 
dered both more intense and of longer duration. A diastolic mitral 
murmur, then, is audible during the ventricular diastole, but generally 
nearer its end than its commencement, sometimes indeed running up 
to the systolic sound, and apparently blending with it. More com- 
monly the rhythm of the heart appears to be altered at the apex. The 
interval between the murmur and the first sound is so short that there * 
is frequently a tendency, on listening at the apex, to reckon the murmur 



480 



DISEASES OF THE VASCULAR SYSTEM. 



as the first sound, the true first sound as the second, and, from its in- 
distinctness in the neighborhood of the apex, either to disregard the 
true second sound, or to look upon it as a mere reduplication ; or if 
there be a systolic murmur, to take the second sound for an accentuated 
portion of it. From the usually peculiar relation of the diastolic mitral 
murmur to the ventricular systole, it is often termed presystolic. 
From the fact of its being determined by the auricular systole, Dr. 
Gairdner names it auricular systolic. There seems no good reason, 
however, why the name diastolic mitral should not be retained for it. 
This murmur is generally of short duration, somewhat deep-toned and 
rough, and to be heard over a very limited area at the apex of the 
heart, or a little to its inner side. It is very rarely audible in the back 
or at the base. It is important to note that a presystolic murmur is 
often attended with a sensible thrill or purring sensation, that it is apt 
to be very irregular or unequal in it's production, and that, above all 
murmurs, it is liable to disappear when the circulation is tranquil, and 
to become distinct when the heart's action is excited. In order to 
identify the presystolic murmur, it is essential either that the pulse 
should be felt while the heart is being auscultated, or that the sounds 
at the base and apex should be simultaneously examined by means of 
a double stethoscope. In both mitral regurgitation and mitral obstruc- 
tion, the ventricle tends to propel a comparatively small quantity of 
blood into the aorta at each systole, and consequently the pulse tends 
to be small and feeble, the arterial tension to be diminished, and more 
or less distinct dicrotism to be manifested. Further, the action of the 
heart, and consequently the pulse, tend soon to become irregular. 

d. Tricuspid Valve Disease. — Actual disease of the tricuspid valve is 
rare ; it is also rare to have a murmur produced at this orifice. A 
direct murmur, a murmur attending the ventricular diastole, is of ex- 
ceedingly infrequent occurrence. A regurgitant or systolic murmur is 
much more common ; but this is more frequently due to overdisten- 
sion of the ventricle or comparative shortness of the musculi papillares, 
and consequent inadequacy of the valves, than to structural disease of 
them. It is sometimes observed in the displaced hearts of persons suf- 
fering from angular curvature of the dorsal vertebrae, in whom also 
the right ventricle is sometimes much hypertrophied. The murmur is 
generally somewhat low-toned, audible most distinctly about the ensi- 
form cartilage, diminishing thence both towards the left apex and the 
base, and absent at the back of the chest. Tricuspid obstruction or 
regurgitation is attended with more or less obvious fulness of the sys- 
temic veins, especially those of the neck and upper arm, and not un- 
frequently distinct pulsation, apparently synchronous with that of the 
ventricle, may be distinguished in them. 

Prognosis. — In attempting to estimate the relative prospects of life 
of patients suffering from the various forms of valvular lesions, many 
different matters have to be taken into consideration. Thus, if the 
affection be due to rheumatic inflammation, we know that the patient 
has special liability to a recurrence of his rheumatism, and consequently 
• to aggravation of his cardiac malady ; if the disease be the consequence 
of senile changes, we know that the valve affection must be, in the 



DIAGNOSIS OF CARDIAC DERANGEMENTS. 



481 



nature of things, progressive ; and both in these and in other cases 
there is often in the condition of the valves something, to be only 
guessed at during life, which renders the danger of embolism always 
imminent. Again, the constant bodily or mental labor to which many 
sufferers are condemned necessarily augments unfavorable symptoms 
and hastens death ; further, any conditions of failing health which 
tend to enfeeble the muscular walls of the heart, tend, on this very ac- 
count, to affect injuriously in a disproportionate degree the due action 
of the organ, and to expedite the fatal issue ; and, lastly, inflammatory 
and other affections of the lungs, which embarrass the pulmonary cir- 
culation, form especially serious and dangerous aggravations of all 
forms of heart disease. 

But, putting aside all these sources of danger, which are more or 
less accidental, and common to all varieties of valve disease, the ques- 
tion remains, " what, cceteris paribus, are the relative prospects of life 
of those suffering from the different forms of valve disease?" and it 
may be added, "what are the special dangers to which they are re- 
spectively liable?" There is no doubt that obstructive disease at a 
valvular orifice is a much less serious matter than regurgitant disease, 
inasmuch as the hypertrophy of the muscular walls of the cavity be- 
hind becomes for the most part accurately adjusted to the increased 
work which is thus thrown upon them. The adjustment is often so 
accurate in the case of aortic valve obstruction, that persons who are 
thus affected occasionally live for years unconscious of the presence of 
disease. Indeed, obstructive aortic valve disease is certainly the least 
serious of all valvular lesions. Obstructive mitral valve disease, 
again, unless it be extreme, is pretty successfully counteracted by 
hypertrophy of the left auricle. Compensative hypertrophy of the 
auricle can, however, scarcely be so efficacious as that of the ventricle, 
since the absence of valves at the entrance of the veins permits the 
increased blood pressure to be propagated backwards through the pul- 
monary vessels. It is certain, indeed, that in a large proportion of 
cases symptoms of cardiac disease manifest themselves before long; 
but, on the other hand, it is also certain that many persons who labor 
under congenital constriction of the mitral orifice live for many years, 
and for a large portion of their lives suffer little. No degree of hy- 
pertrophy can neutralize the effects of regurgitation. Indeed, it is 
questionable whether the hypertrophy which always follows on regur- 
gitation is in any degree compensative of that regurgitation ; whether, 
indeed, it is not to be regarded as the result of an effort to neutralize 
the virtual weakness which the dilatation (always attending regurgi- 
tation) causes. Aortic regurgitant disease is probably the most serious 
and most rapidly fatal of all forms of valvular lesion. Regurgitant 
disease of the mitral valve is certainly a less serious affection than the 
last, and patients often labor under it for many years ; nevertheless it 
is probably more dangerous than obstructive disease of the same orifice. 
The order of danger in which Dr. Peacock places the four lesions 
which have just been considered, and we concur with him in this mat- 
ter, is as follows : first, aortic regurgitant ; second, mitral regurgitant ; 
third, mitral obstructive; and fourth, aortic obstructive. It need 

31 



482 



DISEASES OF THE VASCULAR SYSTEM. 



scarcely, however, be remarked that this order is necessarily often de- 
parted from ; that regurgitation may (although productive of a mur- 
mur) be so slight as to be of comparatively little moment; that ob- 
struction may be so extreme as to lead to the rapid destruction of life. 
Diseases of the right side are so rare, and when present so often 
associated with lesions on the left side, that it is impossible, excepting 
theoretically, to estimate their relative degrees of danger. 

We have previously discussed the various consequences of heart dis- 
ease ; and from what was then said the causes of death in patients 
suffering from the various valvular lesions may for the most part be 
determined. Sudden death, which was formerly so largely attributed 
to heart disease, is not a common sequela of valvular lesion. It is 
most common in regurgitant aortic disease, and in that case is due to 
syncope, or perhaps to cardiac anaemia from non-filling of the coronary 
arteries. 

Treatment — In treating valvular diseases we must never forget that 
we are dealing with affections which, in the nature of things, are in- 
curable ; that valvular defects tend, on the whole, to increase • that 
their ill effects tend gradually to become augmented by the changes 
which take place secondarily to them in the walls and dimensions of 
the cardiac chambers, and are always liable to serious aggravation by 
the presence of any condition, be it normal or morbid, which embar- 
rasses the circulation. Our primary object must, therefore, be to pre- 
vent, or at all events to delay, the supervention of those numerous 
morbid processes and symptoms which have already been adverted to 
as the consequences of heart disease. We cannot repair the injured 
valve. We cannot, and would not if we could, prevent the compen- 
satory hypertrophy Avhich ensues ; we may, however, by forbidding 
excessive muscular exertion, or taking precautions against mental ex- 
citement, or other provocatives of increased cardiac action, prevent in 
many cases that hypertrophy from becoming excessive and therefore 
injurious. • We cannot prevent a certain amount of dilatation from 
taking place in association with hypertrophy ; but by the same meas- 
ures by which we counteract the one we tend also to counteract the 
other ; and, further, since dilatation is to a large extent dependent on 
impairment of muscular strength, we may, by maintaining the general 
strength, maintain also to some extent that of the heart itself. Lastly, 
we may often succeed by careful attention in preventing the recurrence 
of inflammatory attacks, in arresting pulmonary and other congestions 
which react deleteriously on the heart, and in maintaining the quality 
and quantity of the blood in a fairly normal condition. 

Hence a patient whose heart is diseased should abstain from all 
forms of violent and sustained exertion, and should never push even 
what seems to be moderate exercise to the extent of causing shortness 
of breath, or palpitation, or uneasy feelings of any kind, or even fatigue. 
His pursuits and surroundings should be such as do not entail mental 
excitement. He should be protected by proper clothing and other pre- 
cautionary measures against cold. His bodily health should be main- 
tained by the use of wholesome, nutritious, but not too abundant food, 



PERICARDITIS. 



483 



by the cautious employment of stimulants, and by carefully regulating 
the action of his emunctories. 

But, notwithstanding the greatest care, a time comes, sooner or later, 
and comes soon to those who are compelled to work hard for their 
livelihood, when the consequences of the cardiac lesion become pain- 
fully apparent. The patient begins to suffer from palpitation, irregu- 
larity of pulse, shortness of breath, dropsy, jaundice, albuminuria, 
pulmonary apoplexy, angina. But even in these cases it is remarkable 
how often, under the influence of perfect rest and the other items of 
treatment which have been enumerated, all unfavorable symptoms 
subside. Indeed, in the treatment of the symptoms and consequences 
of valvular disease there is no doubt that absolute rest is of far more 
value as a remedial agent than anything else that can be named. But 
in aid of rest other agents may often be beneficially employed. Fre- 
quency of pulsation, and especially irregularity, are almost invariably 
connected with feebleness and irritability of the heart's action. To 
remedy this condition it seems desirable first to give strength to the 
heart's contractions, and next to diminish their frequency. For the 
former of these purposes iron and the vegetable tonics, and possibly 
nux vomica, are valuable ; for the latter probably no drug, at any rate 
in mitral valve disease, is superior to digitalis. A combination of 
digitalis with iron is often of very great value. Belladonna is by 
many preferred to digitalis in the treatment of lesions of the aortic 
valve. To relieve the overloaded venous system, to which so many 
of the resultant phenomena of valvular disease are due, we may em- 
ploy diaphoretics, diuretics, and purgatives, and besides these in some 
cases the removal of blood by leeches or cupping, or by venesection. 
Further, to relieve shortness of breath or engorgement of the lungs, 
or precordial uneasiness, ether, ammonia, lobelia, stramonium, squills, 
ipecacuanha or other expectorants, opium and counter-irritants may all 
of them, under slight modifications of circumstances, be of use. 



PERICARDITIS. 

Causation. — Inflammation of the pericardium is evoked in various 
ways : by extension from the muscular walls of the heart when these 
contain abscesses ; by extension from the pleura, the peritoneum, the 
cellular tissue of the neck, or the posterior or anterior mediastinum, or 
any other neighboring part which is the seat of inflammation ; by local 
injuries, such as penetrating wounds of the pericardium, or the opening 
of sinuses from hepatic or other abscesses into it ; and by the rupture 
of aneurisms, hydatid cysts, and the like. The most frequent and im- 
portant cause of pericarditis, however, is exposure to cold, especially if 
that exposure results in the development of rheumatic fever. Pericar- 
dial inflammation not unfrequently occurs in association with, if not in 
dependence upon, chronic albuminuria, scarlatina, chorea, pyemia, and 



484 



DISEASES OF THE VASCULAR SYSTEM. 



occasionally in connection with tubercular, syphilitic, and carcinomatous 
or other malignant growths. 

Morbid Anatomy. — Inflammation of the pericardium, like that of all 
other serous membranes, is characterized in the first instance by dilata- 
tion of the bloodvessels and consequent hyperaemia; effusion of their 
fluid contents into the substance of the serous membrance, and into the 
subserous tissue; and tendency to proliferation of the endothelium. 
At first, little more than simple congestion and cedematous thickening 
of the membrane are present. But soon inflammatory exudation takes 
place, consisting partly of fibrin, which as it is secreted coagulates upon 
the surface, and remains adherent to it or blended with it ; partly of 
serum, which, containing dissolved albumen and fibrinogen, accumu- 
lates in the pericardial cavity, and separates one surface of the mem- 
brane from the other; and partly of inflammatory corpuscles, derived 
either from the proliferating endothelium or from errant leucocytes, of 
which the majority remain entangled in the coagulating fibrin. 

The relative quantities of solid and of fluid exudation, their charac- 
ters and the changes which they undergo, present great varieties. In 
some cases of pericarditis, which is then often termed "dry/ 3 the whole 
surface becomes covered with a greater or less abundance of false mem- 
brane, but there is little or no accompanying serous effusion. In most 
cases, however, a few ounces of fluid are effused in the course of the 
affection. And occasionally the accumulation amounts to one, two, or 
even three pints. 

The solid exudation or false membrane forms in the early stage of 
its production a thin, slightly coherent lamina, which is scarcely dis- 
tinguishable except by the fact that it robs the serous surface of its 
normal smooth glistening aspect. It soon, however, increases in quan- 
tity by the addition of fresh inflammatory matter to its free surface, 
and may thus by degrees attain the thickness of paper, of card-board, 
or of \ or even J inch. As the thickness increases, so also as a rule 
do the density and closeness of adhesion of its deep surface, and the 
irregularity of its free aspect. At first this last is merely faintly 
granular, but it soon becomes more, or less villous or tuberculated, or i 
pitted with irregular and deepish holes. It is difficult to give in a few 
words a notion of the different appearances which may be presented; 
in some cases the surface is honeycombed ; in others it is ribbed like 
the sand which the waves have just left; in others it has the aspect 
which may be produced by separating two hard smooth surfaces which 
have been stuck together with a layer of butter; in others again the 
exudation has been clearly rolled by the to-and-fro movements of the 
heart into cylindriform pellets, which remain irregularly attached to 
one or both surfaces of the pericardium. And further, irregular bands, 
festoons, or laminse of the same material not unfrequently extend in 
greater or less abundance between the visceral and parietal layers. 

The pericardial fluid is sometimes limpid and colorless, almost like 
water, sometimes more or less opaline, and occasionally distinctly tinged 
with blood. 

In many cases, no doubt, inflammation commences at some one spot 
or circumscribed area of the serous membrane; and, indeed, in mild 



PERICARDITIS. 



485 



cases it not very un frequently remains thus limited, or at all events 
does not become general. More frequently, however, especially in cases 
in which the disease is recognized during life, the whole of the peri- 
cardium is involved. 

In the great majority of cases of pericardial inflammation, resolution 
takes place after a longer or shorter period. The fluid which has been 
effused undergoes gradual absorption ; the false membrane becomes 
organized, contracts, and hardens, and ultimately is converted into a 
more or less imperfect form of connective tissue. In some instances 
circumscribed inflammatory patches result in the formation of those 
opaque, white, cicatrix-like thickenings which are so commonly met 
with on the surface of the right ventricle, and are known as "milk 
patches." In some such cases the opposed pericardial surfaces become 
adherent at one or two points, or over a small area. But in by far the 
larger number of cases of recognized pericarditis, when the inflamma- 
tion has been general, the absorption of the fluid and the coming 
together of the inflamed surfaces end in the coalescence of these surfaces 
to a greater or less extent, and in the obliteration in an equal degree of 
the pericardial cavity. The characters which the resulting adhesions 
display largely depend of course upon the quality and quantity of the 
false membrane from which they have arisen. Sometimes they are thin 
and delicate, and differ little from ordinary connective tissue. Some- 
times they are thick, fibrous, and perhaps oedematous, and may measure 
then J or J an inch thick or more. Sometimes they are almost cartilage- 
like in density and hardness. Sometimes they become the seat of cal- 
careous formations, which may constitute bands or patches of consider- 
able extent. 

In the course of pericardial inflammation, other results besides those 
which have been enumerated may take place. In some cases the newly- 
formed bloodvessels of the false membrane become ruptured, and blood 
in greater or less quantity is effused into its substance, or (if the opposed 
surfaces be not yet adherent) into the pericardial cavity. In this latter 
case the effusion may be so copious as to cause death. In other cases 
the inflammation becomes suppurative, and the pericardial cavity forms 
a large abscess, which may ultimately contain two or three pints of 
pus. Suppurative pericarditis is often very chronic in its progress; 
and there is no reason why the pus should not point and discharge ex- 
ternally in the precordial region, or extend in other directions beyond 
the limits of the pericardium. 

The inflammatory processes of pericarditis, when the attack is slight, 
are probably limited to the serous membrane exclusively; when, how- 
ever, the inflammation is intense or assumes a chronic form, it invades 
the deeper tissues, which then become congested and oedematous, or, if, 
muscular, often degenerated and enfeebled. Hence it happens that in 
pericarditis the integuments of the precordial region become in many 
cases distinctly oedematous; and it is possibly occasionally owing to 
involvement and consequent enfeeblement of the intercostal muscles 
that the intercostal spaces are observed to bulge outwards. It is a more 
important fact that, in a large number of cases, the outer layers of the 
muscular walls of the heart become to a greater or less depth obviously 
degenerated, softened, and weakened. 



486 



DISEASES OF THE VASCULAR SYSTEM. 



Symptoms and Progress. — The symptoms of pericarditis are so com- 
monly associated with those of the malady in the course of which it 
arises, and with those due to endocarditis, Avhich is so often developed 
in common with it, that it is not altogether easy to disentangle them 
entirely from those which belong to these other conditions. Pericarditis 
is in many cases so mild a disorder that it is attended with few or no 
symptoms of any importance. In other cases it is one of the most 
perilous maladies with which we have to deal, and its symptoms are 
correspondingly severe. But, between these extremes, cases of all grades 
of intensity are met with. 

In its mildest form, pericarditis often entirely escapes detection or it 
is recognized only by the accidental discovery of the presence of peri- 
cardial friction; in most such cases, however, there is at some time or 
other some slight precordial pain or uneasiness, together with exten- 
sion of cardiac dulness and more or less obvious febrile disturbance. 
Most cases of what are termed "latent" and "dry" pericarditis belong 
to this group. 

In describing the symptoms of more aggravated cases of pericarditis, 
it will be convenient to divide them into local and general, and to dis- 
cuss these seriatim. The local symptoms are directly due to the condi- 
tion of the pericardium and its influence on surrounding parts. The 
patient complains generally of pain and tenderness in the region of the 
heart. He winces if pressure be made over the prsecordium, and still 
more if it be made in the epigastric region. The pain varies in char- 
acter, is aching, cutting, burning, or a mere sense of soreness, and occa- 
sionally extends from the heart to the left shoulder and down the left 
arm. It is usually augmented by movement of the diaphragm, and 
hence the patient tends to breathe rapidly, shallowly, and with little 
abdominal motion. When the pain and tenderness are very severe, he 
usually lies upon his back, and, while moving his limbs with tolerable 
freedom, keeps his trunk almost entirely still. The roughening of the 
pericardial surface which takes place at the commencement of the dis- 
order is attended with distinct friction-sound, the characters of which 
have been already described. This usually commences at the base or 
apex, or along the right side, but soon becomes general ; and having 
lasted for an uncertain time, a few hours, or it may be a day or two, or 
even longer, gradually or more or less suddenly vanishes. The further 
progress of the case will alone determine whether this disappearance is 
due to adhesion having taken place, and is therefore permanent, or 
whether it is due to increase of fluid effusion and* consequent separation 
of the pericardial surfaces from one another. In the latter case, the 
friction reappears with the absorption of the fluid, and the final disap- 
pearance due to adhesion is a subsequent event. It must be added that 
pericardial friction-sound is usually rendered more intense by the ap- 
plication of pressure to the prsecordium, that its intensity is often dis- 
tinctly modified by the movements of respiration, and, further, that 
pleuritic sounds developed along the edges of the precordial region 
often have a distinct cardiac rhythm impressed upon them. Other 
phenomena of more or less importance which may often be observed 
are oedema of the integuments over the cardiac region, a perceptible 



PERICARDITIS. 



487 



thrill arising from the grating of the two rough pericardial surfaces 
upon one another, to be felt by applying the open hand to the region 
of the heart, and more or less complete masking of the normal heart- 
sounds by those due to pericardial friction. It is scarcely necessary to 
add that all the phenomena (local and general) which have been pre- 
viously described as belonging to pericardial effusion, are commonly 
added with typical completeness to those which have been now detailed, 
and indeed that they constitute an essential element in the clinical de- 
scription of pericarditis. 

The influence of pericarditis on the action of the heart and on the 
pulse is various. Early in the disease the heart itself may be little 
affected; more commonly its movements are increased in frequency, 
and the pulse is at the same time harder and fuller than natural. With 
the increase of effusion the beats of the heart become accelerated and 
diminished in strength; the pulse consequently becomes small and 
feeble, and often very irregular. Moreover, its rate is peculiarly apt 
to be increased by any slight excitement or muscular effort. 

Among the general symptoms referable to pericarditis are the follow- 
ing : first, those of inflammatory fever, namely, increase of temperature, 
dryness of tongue, thirst, loss of appetite, and scanty high-colored urine; 
second, shortness of breath, amounting often to dyspnoea or orthopnoea, 
and frequent short, hacking cough ; third, vomiting, a general aspect 
of distress, a look of anxiety, with pinched features and a pallid, or 
sometimes congested countenance; weariness, want of sleep, tossing of 
the arms, irritability, rambling, and occasionally (especially towards the 
close of fatal cases) maniacal delirium, convulsions, or coma. These 
latter phenomena, however, which are certainly not unfrequently asso- 
ciated with pericarditis, seem almost invariably to have been observed 
in cases where the pericarditis was distinctly rheumatic, and where, 
therefore, it is possible that they may have been due to some other 
cause. Tetanic spasms and risus sardonicus have also occasionally been 
noticed in cases of rheumatic pericarditis. 

Recovery from simple pericarditis is attended with the gradual sub- 
sidence of the symptoms which belong to the disease. In slight cases 
convalescence is often very rapid and complete. Generally, however, 
when there has been much pericardial effusion, and the symptoms have 
been severe, the amendment is slow ; and more or less permanent ill- 
health is apt to remain. Pain, tenderness, cough, difficulty of breath- 
ing while the patient is at rest, and fever gradually subside, the patient's 
appetite improves, and he begins to enjoy refreshing sleep. The pulse, 
however, frequently remains for a long while preternaturally quick, or 
on the other hand becomes slow and intermittent, and the precordial 
prominence and increased dulness still continue excessive. Moreover, 
the patient often, under these circumstances, remains incapable of taking 
active exercise on account of the persistent ready development of cardiac 
uneasiness, palpitation, and shortness of breath. These symptoms may 
also in their turn subside more or less completely. 

Adhesion of the pericardium can rarely be diagnosed with certainty 
in the absence of a distinct history of pericarditis. It is often attended, 
however, with more or less persistence of enlarged area of dulness, with 



488 



DISEASES OF THE VASCULAR SYSTEM. 



permanent and unalterable elevation and displacement outwards of the 
apex beat, together perhaps with palpitation and dyspnoea, and some of 
the general symptoms of cardiac disease. Moreover, a pericardium 
which has once been inflamed is apt, under the influence of exciting 
causes, to become again inflamed, notwithstanding the complete oblit- 
eration of its cavity. 

Pericardial suppuration generally takes a chronic course. The com- 
mencement of suppuration may be attended with rigors and elevation 
of temperature. The former may recur from time to time; the latter 
probably continues ; and soon the fever assumes a distinctly hectic type. 
The local phenomena are not always very well marked ; there will 
probably be some persistence or increase of pain and tenderness; grad- 
ual extension of precordial d illness ; and augmenting distension of the 
precordial region with distinct and increasing oedema of the integu- 
ments. 

Severe pericarditis not unfrequently ends sooner or later in death. 
If death occur during the height of the disease it may be the result of 
one or other of the cerebral complications which have been enumerated, 
or of asphyxia due to pulmonary complication ; but in the majority of 
cases it is the consequence either of slow asthenia or of an attack of 
syncope. When death takes place at a later period, it is not unfre- 
quently dependent on the gradual supervention of the ordinary conse- 
quences of heart disease, namely, pulmonary congestion with pulmonary 
apoplexy, or systemic venous congestion with anasarca, and affection 
of the liver, kidneys, and other organs. Suppurative pericarditis is 
generally fatal. 

Myocarditis. 

Causation and Morbid Anatomy. — Inflammation of the muscular 
tissue of the heart rarely occurs except in connection with peri- or endo- 
carditis. In pericarditis, as we have already pointed out, a greater or 
less thickness of the muscular walls in contact with the inflamed serous 
membrane is often distinctly implicated ; and there is no doubt that 
their inner aspect may be similarly involved during the course of an 
attack of endocarditis. It may even happen that in some situations the 
cardiac walls become thus affected in their entire thickness. Occasion- 
ally pysemic abscesses, or abscesses due to embolism, are found stud- 
ding their substance. These are mostly very small. But abscesses of 
considerable bulk have been described. 

The early effects of inflammation are to diminish the cohesion of the 
affected tissues and to render them less resistant than natural. But 
subsequently, if resolution do not take place, these become contracted 
and hardened, and assume a cicatricial character. Under either of 
these conditions, especially if the morbid processes be circumscribed, 
yielding of the affected walls may take place, and the foundation of 
« cardiac aneurism be laid. It is possible, of course, for abscesses to 
burst into the pericardium, exciting inflammation of that membrane, 
or into the cardiac cavities, and thus to evoke the phenomena of em- 
bolism or pyemia. In many cases, no doubt, the inflamed muscle 
becomes completely restored. 



ENDOCARDITIS. 



489 



It is impossible to assign any specific symptoms to the presence of 
myocarditis. 

Endocarditis. 

Causation. — The causes of inflammation of the lining membrane of 
the heart's cavities are to a large extent identical with those which 
excite pericarditis and myocarditis. The various local causes, however, 
to which pericarditis may be due, can scarcely be operative upon the 
endocardium. Endocarditis is occasionally the result of the accidental 
rupture of valves or of chordae tendineae; more commonly it depends 
on exposure to cold ; but by far its most frequent cause is the presence 
of rheumatism. It may also be caused by extension from abscesses in 
the muscular parietes. Again, like pericarditis, it is often developed 
in connection with chorea and scarlet fever. A chronic form of endo- 
carditis also may occur in connection with the syphilitic cachexia, 
chronic alcoholism, Bright's disease, and other affections inducing a 
chronic dyscrasia. 

Morbid Anatomy. — In the great majority of cases endocarditis is 
limited to the left side of the heart and to the valves or their imme- 
diate vicinity. Its presence is indicated by increased vascularity of the 
affected areae, infiltration and inflammatory overgrowth of the tissues 
which are involved, and consequent increase of thickness, and develop- 
ment of warty growths or granulations upon the surface. The thicken- 
ing, which is mostly attended with opacity and more or less softening, 
varies greatly in degree, and, when it involves the thin curtains of the 
valves or the delicate chordae tendineae, causes them to become puckered 
or contracted. The granulations are in the first instance mere points ; 
but they soon increase in size, sometimes becoming rounded, bead-like 
bodies, sometimes papillary excrescences, sometimes rounded masses 
from the size of a tare up to that of a filbert. Frequently the various 
outgrowths coalesce to a greater or less extent, forming warty, botry- 
oidal, or cauliflower-like masses, and in some cases pendulous fringe- 
like but irregular processes, which may attain a length of one or two 
inches. During the inflammatory process it is not uncommon for 
ulceration to take place. If this affect the valves it leads to their par- 
tial detachment, to their attenuation at points and the production of 
valvular aneurisms, or to their perforation ; if it involve the tendinous 
cords, to their laceration. 

When inflammation attacks the aortic valve the granulations which 
characterize it first appear as a fringe along the festooned inner mar- 
gins of the lunulae, but with the extension of disease they may cover 
to a greater or less extent the whole of the under surface of one or 
more of the cusps and even extend downwards on to the septum. 
They often, indeed, hang at length from the free edge of the valve, 
which is then usually thickened, contracted, and irregular in form. 
The aortic aspect of the valve is rarely the seat of granulations. 

When the mitral valve is inflamed, granulations appear on its auric- 
ular aspect a little within the free edge, whence they may extend over 
the greater part of that surface and thence on to the auricular walls. 
With the development of granulations there is usually more or less 



490 



DISEASES OF THE VASCULAR SYSTEM. 



thickening and contraction of the free edge of the valve, and at the 
same time some contraction of the valve at its base, in virtue of which 
the orifice becomes diminished in capacity. The chordae tendinese also 
are apt to become the seat of granulations, to undergo thickening and 
shortening, and to become blended to a greater or less extent with the 
valvular curtains. Granulations are rarely met with on the ventricu- 
lar surface of the valve. 

Inflammation, when it attacks the valves on the right side of the 
heart, produces exactly similar effects to those above described. 

Inflammation of the endocardium is not always acute, or always lim- 
ited to the valves. It is well known that in the course of regurgitant 
aortic disease the surface of the septum ventriculorum for half an inch 
or an inch below the valve, generally presents more or less cicatricial 
thickening, and occasionally marked contraction. The thickening is 
the result of chronic inflammation probably due to the constantly 
recurring impact of the refluent blood-stream against the ventricular 
walls in this situation. Again, we occasionally find, especially in con- 
nection with some forms of so-called " atheroma" of the arteries, the 
lining membrane of the left ventricle studded w T ith irregular patches of 
opaque thickening. These are due to hypertrophy, with more or less 
degeneration, of the endocardium, and are also doubtless of inflamma- 
tory origin. 

Symptoms and Progress. — The symptoms of endocarditis, apart from 
those of the disease (if any) with which it is, associated, and from those 
of the lesions to which it gives rise, are neither striking nor serious. 
The symptoms, indeed, which are usually ascribed to this affection, are 
mainly made up of those of acute rheumatism and those of valvular 
obstruction or incompetence. And it must be admitted that it is by 
the development of the valvular lesions, which are an almost invariable 
accompaniment of endocarditis, that we mainly assume its presence 
and trace its progress. It is needless to say that the discovery of val- 
vular mischief is no proof of the presence or even of the pre-existence 
of endocarditis. But if, in the progress of any one of those diseases 
of which endocarditis is a common complication, we detect the presence 
of a cardiac murmur which had not previously existed, and if further 
observation proves this to be a permanent phenomenon, or if changes 
in it indicative of increasing mischief take place, or if additional mur- 
murs become developed, we cannot reasonably doubt that endocarditis 
is present. The same conclusion may be fairly arrived at when a 
young person who is known to have been hitherto healthy, presents 
vague symptoms of ill-health, and reveals under the stethoscope a 
newly-developed and persistent valvular murmur. It is very impor- 
tant, however, to note that, in forming a judgment with respect to 
cases of this kind, there are many sources of fallacy to be avoided. 
We must be careful that we do not mistake a pericardial rub for an en- 
docardial murmur ; that we do not hastily assume that a murmur which 
we hear for the first time has not existed from some previous attack 
of rheumatism x>r from birth ; and that we do not take a functional or 
ansemic murmur for one of organic origin. On the other hand, we 
must not too hastily assume that, for example, in a case of rheumatism 



TREATMENT OF CARDITIS. 



491 



in which the heart is known to have been injured in some previous 
attack, the cardiac disease which we recognize is all of old date ; we 
must not forget that direct murmurs due to granulations do occasion- 
ally disappear; and, further, we must always recollect that inflamma- 
tory vegetations may be formed on the valves, and more perticularly 
on the auricular aspect of the mitral, which never impair the action of 
the heart and never give rise to abnormal sounds. 

The remaining indications of the presence of endocarditis are slight 
and fallacious. From the position of the inflamed arere it is scarcely 
possible that precordial tenderness should be present ; and, indeed, it 
is rarely, if ever, observed. More or less uneasiness or pain in the 
region of the heart may, however, be complained of. From the small- 
ness of the extent of the inflamed surface we should scarcely expect 
much febrile disturbance to be evoked ; nor, as a rule, is simple endo- 
carditis attended with marked fever. Still there may be elevation of 
temperature, thirst, scanty urine, and other indications of the febrile 
condition. Again, here, as in pericarditis, we may naturally look for 
some excitement or other modification of the action of the heart. It 
generally acts more frequently and powerfully than natural. 

The prognosis of endocarditis is very serious. It is rare indeed for 
perfect recovery to take place. Moreover, the patient remains, for the 
most part, liable to fresh attacks of inflammation, and consequent in- 
crease of valvular lesion. The results of endocarditis are mainly those 
which have already been considered under the head of valvular disease. 
The phenomena will, of course, vary according to the valve affected, 
and according to the degree and kind of its affection, and need not be 
again discussed. It must not be forgotten that it is in connection with 
endocarditis and its local consequences far more than with any other 
form of disease involving the endocardium, that detachment of solid 
particles or masses takes place which are conveyed as emboli to the 
brain, liver, spleen, kidneys, lungs, and other organs ; and that the 
liability to this detachment has little or no obvious relation with the 
severity of the cardiac lesion. 

Treatment of Inflammation of the Heart and Pericardium. 

In the great majority of cases of the several forms of cardiac in- 
flammation which have been passed in review, the cardiac affection 
becomes developed in the course of other diseases, such as rheumatism, 
Bright's disease, and pyaemia, for which the patient is already under 
treatment. The treatment, therefore, of these latter maladies forms 
an essential element in the treatment of the heart affections which 
complicate them. It is important, however, to consider whether any, 
and if so what, additional treatment may be directed against the car- 
diac lesions. 

In the treatment of pericarditis the abstraction of blood is generally 
regarded as a most important remedial measure. Blood may be taken 
by venesection from the arm ; but it is probably most conveniently, 
and best, removed from the precordial region by cupping or leeching. 
To be efficacious, bloodletting should be performed early, while the 



492 



DISEASES OF THE VASCULAR SYSTEM. 



symptoms are yet acute ; and it should be, so far as is compatible with 
the patient's age and condition, free, in order to obviate as much as 
possible the necessity for its repetition. A oozen or twenty leeches 
may be applied to tie chest of an otherwise healthy adult, and the 
bleeding subsequently encouraged by fomentations or poultices. In 
slight cases at an ea "ly period, and in severe cases after removal of 
blood, counter-irritation is of considerable value. It relieves pain and 
uneasiness, and probably promotes the absorption of fluid. A large 
mustard plaster, or cotton-wool saturated with turpentine or spirits of 
wine, and covered with some impermeable tissue, may be applied to 
the prsecordium ; or iodine paint or blistering fluid may be painted 
over the part ; or simple fomentations, as hot as the patient can bear 
them, may be persisted in. There is, it may be added, a practical ob- 
jection to the use of applications which blister the surface, namely, that 
they interfere with that frequent examination of the cardiac region 
which is so important. Of the value of opium in this, as in almost all 
other inflammatory affections, there can be no doubt. It may gener- 
ally be safely administered, and in large doses, excepting, perhaps, 
when the heart shows signs of great enfeeblement, when the circulation 
is embarrassed, the respirations are rapid and shallow, and the skin 
dusky. When these latter phenomena supervene, ammonia, ether, 
alcohol, and other stimulants are indicated. In order to reduce in- 
flammation, and to remove the products of inflammation, it was for- 
merly deemed essential to put patients under a course of mercury or of 
iodide of potassium. These remedies, however, are probably ineffica- 
cious except in certain constitutional conditions. Again, diuretics and 
purgatives have been largely advocated for the purpose of removing 
fluid accumulations from the serous cavities. But there is little proof 
that they have any appreciable influence in this respect. It may, 
nevertheless, be useful when febrile temperature is present to employ 
some of those agents, namely, aconite, veratrum, or quinine, which are 
known to reduce temperature. But the most efficient means by which 
to effect the removal of dropsical accumulations is to improve the 
patient's general health. And on this and other grounds it is always 
important to bring him under the influence of tonic treatment as soon 
as ever the condition of the digestive organs allows of its employment. 

The above remarks as to treatment more immediately refer to peri- 
carditis. But they are to some extent applicable to endocarditis. It 
must be borne in mind, however, that local bleeding and local medi- 
cation of all kinds are necessarily less efficacious in endocarditis than 
in the other ; and, further, that as endocarditis is (except in its remote 
consequences) a far less dangerous and severe affection than pericarditis, 
a less active plan of treatment is generally needed. 

When in pericarditis the accumulation of fluid appears to be 
seriously interfering with the action of the heart, especially if it persist 
despite all treatment, or when we have reason to suspect the presence 
of pericardial suppuration, the question whether paracentesis should 
be performed for the removal of the fluid will perforce present itself. 
The operation is one which has been neither frequently performed, nor 
with much success ; moreover, it is an operation of considerable deli- 



MORBID GROWTHS OF THE HEART. 



493 



cacy and difficulty; still it can scarcely be doubted that it should be 
attempted under the circumstances that have been enumerated. The 
chief danger to be avoided is that of puncturing the heart, the next 
that of wounding the internal mammary artery. To avoid the former 
danger it is important first to determine accurately the lateral boun- 
daries of the distended pericardium, and next to^satisfy oneself, by the 
presence or absence of sensible impulse, over what area (if any) the 
heart is in contact with the anterior thoracic parietes, and then care- 
fully to make an opening into that part of the pericardium from which 
the heart seems to be remote. The mammary artery runs down be- 
hind the costal cartilages, a little outside the sternum. The most 
eligible spot for puncture is usually towards the inner extremity of the 
fourth or fifth intercostal space close to the sternum. It is probably 
the safest plan to divide the soft tissues with the scalpel one by one 
until the parietal layer of the pericardium is reached, and then to 
puncture carefully with a fine trocar and canula. If serum escape 
the entrance of air should be prevented ; if pus, it may be advisable to 
wash out the cavity, and even to inject a weak solution of chlorinated 
soda or Condy's fluid. In some cases it may be well to make a pre- 
liminary puncture with a fine aspirating needle. 



MORBID GROWTHS AND PARASITES. 

Various forms of morbid growths are liable to affect the heart, the 
pericardium, or both, among the more important of which are tubercle, 
syphilitic gummata, sarcomata, and other varieties of malignant disease. 

1. Tubercle is of infrequent occurrence, and generally takes place 
in connection with widespread distribution of the disease. Miliary 
tubercles are occasionally found imbedded in the substance of the 
muscular walls. Their most common seat, however, is the pericardial 
serous membrane. In this situation they may occur in small scattered 
groups only, or may be thickly and pretty generally distributed ; and, 
especially in the latter case, are often associated with more or less 
abundant inflammatory exudation. Cheesy tubercle in considerable 
masses, and generally associated with thick and dense adhesions, is also 
occasionally observed in the pericardium. 

The symptoms of cardiac and pericardial tuberculosis are generally 
lost in those of more advanced tubercular disease of other organs. If, 
however, they be sufficiently pronounced to attract attention, they are 
indistinguishable from those of subacute or chronic pericarditis. 

2. Syphilitic Gummata. — Syphilitic affection of the heart is not un- 
common. The condition which is now very generally regarded as such 
is characterized by the presence of fibroid infiltration, of greater or less 
extent, of the cardiac walls, with imbedded caseous masses, somewhat 
closely resembling the so-called " knotty" tumors of the liver and with 
more or less indurated thickening and adhesion of the pericardium. 
True gummata of recent formation have also been observed. Microscop- 



494 



DISEASES OF THE VASCULAR SYSTEM. 



ically, the diseased tissues present, as do those of gumraata developed 
in voluntary muscles, overgrowth of the connective tissue between the 
muscular fibres, with more or less fatty or caseous conversion of certain 
parts, in which the involved muscular fibres share. The disease may 
implicate any part of the heart's walls, but most commonly affects those 
of the ventricles. Sometimes it forms tumors, which may project from 
the outer aspect of the heart, or encroach upon its cavities; sometimes 
it leads to thinning of certain parts of the walls, and to aneurismal dila- 
tation. It must be added that fibroid change of the cardiac walls may 
be due to other causes than syphilis, and that the specific origin, there- 
fore, of all such cases must not be hastily assumed. 

The conditions here spoken of may, in a clinical point of view at 
all events, be combined. They are chronic in their progress, and are 
not unfrequently associated with adhesion of the pericardium, lesion of 
the valves, and hypertrophy, dilatation or other modifications either 
of the walls or cavities of the heart. The symptoms, therefore, which 
they induce, although liable to considerable variation of detail, are 
essentially those characteristic of chronic heart disease, and mainly of 
those conditions or those stages of disease in which the heart is enfeebled 
and incompetent efficiently to carry on the circulation. Dropsy is of 
common occurrence, and sudden death not unfrequent. The disease 
occurs almost exclusively among persons of middle or advanced age. 

3. Malignant disease affects the pericardium, as it does other serous 
membranes, only much less frequently. It may occur here in the form 
of miliary granulations, or scattered circular plates, or nodulated out- 
growths. It is always secondary, and probably never attains sufficient 
proportions to cause obvious symptoms. Malignant disease of the mus- 
cular walls of the heart is also not common, and is probably always of 
secondary origin. Generally it occurs there in the form of small im- 
bedded tumors, which are of no practical importance. Occasionally, 
however, it forms masses, as large, perhaps, as a hen's egg or an orange, 
which encroach on the cavities or orifices of the heart, and constitute a 
more or less serious impediment to the circulation. In some instances, 
sarcomatous and other growths, originating in the posterior mediasti- 
num, involve the heart by continuity; they steal, as it were, along the 
vessels at the base, and then gradually infiltrate the muscular parietes 
of the auricles and ventricles, separating the muscular fibres from one 
another, and causing general increase of thickness. In these cases no 
tumors may be developed, and microscopic examination maybe needed 
for the detection of the nature of the morbid process which has been 
going on. Among the varieties of malignant disease which have been 
found involving the heart and pericardium may be mentioned scirrhus, 
encephaloid, melanotic cancer, lymphadenoma, and sarcoma. 

Malignant disease of the heart and pericardium has rarely, if ever, 
been diagnosed during life, and rarely indeed gives evidence of its 
presence by symptoms referable to the heart. It is obvious, however, 
that the symptoms to be looked for are those indicative of cardiac ob- 
struction and weakness, and that the supervention of such symptoms 
in the progress of malignant disease might suggest the possibility of 
cardiac involvement. 



DEGENERATIONS OP THE HEART. 



495 



4. Fatty Growth. — The presence of a small quantity of fat upon the 
surface of the heart, mainly in the course of the transverse and longi- 
tudinal sulci, is extremely common, especially in persons who have 
attained middle life, or who present a general accumulation of fat 
throughout their connective tissue. This condition is of no importance. 
But occasionally, in persons of great obesity, fatty growth becomes ex- 
cessive, and encroaches seriously upon the substance of the heart, not 
only investing the organ more or less completely, but invading the 
substance of its walls, separating the muscular fibres from one another, 
and imparting to the walls in places (more especially in the right ven- 
tricle) the softness and general aspect of simple fat. 

The symptoms referable to this affection (which is sometimes de- 
scribed as a form of fatty degeneration) are those of cardiac feebleness 
and incompetence. 

5. Parasites are of very exceptional occurrence in connection with 
the heart. The trichina spiralis has never been found in it. The 
cysticercus celhihsai has been discovered there, but not as productive of 
symptoms. Hydatids also have occasionally been met with, varying 
from the size of an orange downwards, and either imbedded in the 
substance of the muscular walls, or occupying the subserous tissue of 
the visceral pericardium. 

The symptoms to which they would give rise are either those of in- 
terference with the due performance of the cardiac functions ; or those 
of suppuration, to which such cysts are liable; or those of pericarditis, 
dependent either on extension from the inflamed cyst, or on its rupture 
into the pericardium ; or, lastly, those of the discharge of the hydatid 
contents into the interior of the heart. 

Treatment. — It is impossible to lay down rules in regard to the treat- 
ment of cases in which the heart is involved in adventitious growths or 
the seat of parasites. The symptoms which they are likely to induce 
are mainly those of cardiac debility and incompetence, and the treatment 
must be adapted to the symptoms which are present. It may be said, 
however, generally, that diffusible stimulants and tonics are indicated. 



DEGENERATIONS OF THE HEART. 

Degenerative changes affect the pericardium, the muscular walls of 
the heart, the endocardium, and the coronary arteries. Those impli- 
cating the pericardium are mainly the results of inflammation, and have 
been already sufficiently considered. Those involving the muscular 
tissue, the endocardium, and the vessels we proceed briefly to discuss. 

Degenerative Changes in the Muscular Walls. 

Causation and Morbid Anatomy. — We have previously pointed out 
that, under the influence of starvation and of various wasting diseases, 
more especially phthisis, the heart becomes remarkably diminished in 



496 



DISEASES OF THE VASCULAR SYSTEM. 



bulk. But this change is due to atrophy alone, the muscular fibres 
becoming simply attenuated, without presenting any structural change. 

Of actual degeneration, three varieties are generally described, 
namely, fatty or yellow degeneration, granular or brown degeneration, 
and fibroid degeneration. 

1. Fatty degeneration in an advanced condition is indicated by soft- 
ness of the affected tissues, opacity, a peculiar pale-buff color, and, it 
may be, obvious greasiness. Under the microscope the muscular fibres 
are found to have lost, in a greater or less degree, their natural stria- 
tion, to be studded with minute refractive oily molecules, and to be, as 
a rule, more friable than in health. In the early stage it sometimes 
happens that the oily particles are accumulated only at the poles of the 
nuclei belonging to the muscular fibres, or arranged in longitudinal 
strings; but with the progress of the morbid process the molecules 
become more numerous ; and in advanced cases the fibres may have 
lost all their normal characteristics and become converted into opaque 
irregular cylinders of accumulated fatty molecules. 

Fatty degeneration occurs under various conditions. It is frequently 
the result of inflammation, and when developed in connection with 
pericarditis occurs more especially in the layer of muscular fibres im- 
mediately subjacent to the visceral lamina of the pericardium. It is 
sometimes observed in acute diseases, and is said to be not uncommon 
in certain fevers. We have recognized it remarkably developed in a 
child that died of acute purpura. It is a common condition of advanced 
life, and especially of advanced life attended with certain diseases or 
morbid tendencies, such as heart disease, chronic bronchitis, Bright's 
disease, hepatic disease, arterial degeneration, and gout. It is common 
also, in advanced life, as an immediate consequence of obstructive dis- 
ease of the coronary arteries, or of any other morbid condition impair- 
ing the vitality of certain portions of the organ. 

When the degeneration occurs in connection with inflamed serous 
membrane, the affected lamina appears to the naked eye ansemic, and 
in other respects but little altered. When it is due to general disease 
or to disease influencing the heart generally, the whole organ may be- 
come pallid and softened, but more frequently the tissues are mottled 
with fattily degenerated spots, a condition which is very often peculiarly 
distinct in the carnese columnar and at the inner surface of the ven- 
tricles. When the disease is secondary to obstructed arteries the de- 
generation usually occupies a definitely circumscribed patch, which 
presents, as a rule, remarkable softness and friability. 

2. Granular degeneration is generally uniformly distributed through- 
out the muscular tissue of the heart, which assumes a brownish hue. 
The muscular fibres are studded with longitudinal strings of brownish 
particles, the exact chemical constitution of which is not known. The 
circumstances which determine this form of degeneration seem to be 
the same with those to which general fatty degeneration is also due. 

3. Fibroid degeneration affects portions of the cardiac walls only, and 
is comparatively common on the right side. The affected tracts become 
grayish, dense, and hard — changes which are due in different degrees 
to overgrowth of the fibroid tissue and to wasting of the muscular 



DEGENERATIONS OF THE HEART. 



497 



fibres, and their conversion into, or replacement by, fibroid tissue. The 
change is probably in many cases indistinguishable from the conse- 
quences of syphilis; but is in some instances a sequela of myocarditis. 
Again, hypertrophy of the heart, and especially that form of it which 
is secondary to Bright's disease, is often made up partly of overgrowth 
of muscular tissue, partly of overgrowth of the intervening connective 
tissue, and in some cases the latter element becomes disproportionately 
abundant, and the heart consequently, in a sense, degenerate and en- 
feebled. 

Symptoms. — The symptoms of degenerative affections of the muscu- 
lar walls of the heart are mainly those of cardiac weakness and in- 
competence. Enfeeblement from degeneration is one of the recog- 
nized causes of sudden death; and it is an important fact that sudden 
death is liable to occur in those in whom the condition is not yet far 
advanced, and who have not yet presented definite symptoms of cardiac 
disease. Rupture of the heart not uncommonly occurs in those cases 
in which local softenings are due to obstruction of branches of the coro- 
nary artery. 

Degenerative Changes in the Valves and Endocardium. 

Causation and Morbid Anatomy. — Fibroid, fatty, and calcareous 
changes, or degenerations of the endocardium, are among the most 
frequent causes of disease of the heart. For the most part they come 
on with advancing years, and may be regarded (with the correspond- 
ing conditions of the arterial system) as among the chief consequences 
and indications of senile decay. They are apt, however, to manifest 
themselves even in early adult life, especially among those who have 
lived intemperate or overlaborious lives, or have suffered from syphilis, 
or are the subjects of chronic Bright's disease. They are very apt also 
to supervene on ordinary endocarditis ; and hence it is often difficult 
(except from the history) to distinguish between degenerative lesions 
of primary origin and those which are the consequences of bygone acute 
endocardial inflammation. It must be remembered, however, that the 
changes which are here roughly grouped together as degenerations, 
for the most part probably take their origin in a form of chronic en- 
docarditis, a subject which will be more fully discussed when we come 
to speak of endoarteritis and degeneration of arteries. 

Degenerative changes may manifest themselves at any point of the 
endocardial surface, but far more frequently involve the valves than 
other parts. The endocardial lining of the left ventricle is more com- 
monly affected than that of the other cavities ; and the aortic and mi- 
tral valves far more commonly than the valves of the right side. In 
some cases the valves present simply a few opaque, buff-colored (athe- 
romatous) patches ; in some they manifest more or less general fibroid 
thickening, a condition which is usually accompanied by a greater or 
less amount of contraction, and often by some fatty or calcareous de- 
posit ; in some cases they are rendered thick, nodulated, and irregular 
from the accumulation of combined fibroid, fatty, and calcareous de- 
posit, and then, if the condition be far advanced, project as more or 

32 



498 



DISEASES OF THE VASCULAR SYSTEM. 



less rigid processes across the orifices to which they belong, become 
blended to a greater or less extent with one another at their bases, and 
reduce the valvular aperture to a mere chink; in some cases, again, 
the degenerate tissue undergoes erosion, excavations form, and finally 
perhaps the valve becomes perforated or ruptured. These changes are 
generally not strictly limited to the valves; they are apt to be pro- 
longed from the aortic to the aorta or the septum ventriculorum, and 
from the mitral to the chordse tendinese, which become thick, short, 
and sometimes incorporated with one another. The chordae tendinese, 
like the valves, occasionally become lacerated. 

Symptoms. — It is obvious that the conditions here described may pro- 
duce all varieties of valvular defects, singly or in combination ; and 
more especially the same defects as those which commonly result from 
acute endocarditis, namely, obstructive and regurgitant disease of the 
aortic and mitral orifices. The changes are chronic, and the symptoms 
which they induce creep on insidiously ; so that it often happens that a 
patient has had the disease upon him for years before its presence be- 
comes distinctly revealed. Indeed, the first clear indication of heart 
disease is sometimes due to the sudden rupture of a valve, or to some 
other untoward complication or event; and we are often astonished to 
find post mortem how extreme a degree of contraction of the aortic or 
even of the mitral orifice has been compatible, not merely with life, but 
.with life passed in comparative ease and comfort. 

The early symptoms of degenerative disease of the valves are usually 
vague, comprising, perhaps, some degree of irregularity of the pulse, 
more or less shortness of breath, occasional neuralgic pain or uneasiness 
in the region of the heart, attacks of giddiness or faintness, and not un- 
frequently more or less impairment of the digestive functions. It must 
be added that, inasmuch as the cardiac affection is usually associated 
with degenerative changes in the arteries and sometimes in other tis- 
sues, the symptoms due to these latter become mingled with those due 
to the heart disease, and may consequently be to some extent indicative 
of the condition of the heart. Among such indications may be men- 
tioned the presence of rigid or otherwise diseased arteries, as revealed 
by the condition of the pulse or by cerebral symptoms, and the presence 
of the arcus sinilis. The symptoms of the declared disease are mainly 
those of the vulvular lesions which have been already fully considered. 
The chief practical point to be remembered, is that, however slow the 
symptoms may have been in attaining serious development, the morbid 
processes on which they depend are in the nature of things progressive 
and tend surely to a fatal issue. 

Degenerative Changes in the Coronary Arteries. 

The coronary arteries of the heart and their branches are especially 
liable to all those degenerative changes which affect the lining mem- 
brane of the heart and the arterial system generally. Their parietes 
consequently become thickened with fatty or calcareous deposit, and 
their channels reduced in size or obliterated. These latter conditions 
involve the imperfect nutrition of the parts to which the affected ves- 



ANEURISM OF THE HEART. 



499 



sels lead, and induce those localized fatty changes, attended with dis- 
coloration of tissue and softening, which have been already adverted to. 

No specific symptoms can be referred directly to disease of the coro- 
nary arteries. Angina pectoris has been asserted to occur with special 
frequency in these cases. But it must be recollected that arterial de- 
generation is usually present in a greater or less degree in persons ad- 
vanced in years, and is usually then associated with other degenerative 
affections of the heart. 

Treatment. — Degenerative conditions of the heart, as of other organs, 
call for all those measures, tonic, alimentary, and hygienic, calculated 
to maintain or to improve the general health ; but they need also special 
precautions and special items of treatment, according to the particular 
phenomena and dangers which each case presents. These have been 
sufficiently indicated on an earlier page under the head of the treat- 
ment of valvular derangements. 



ANEURISM OF THE HEART. 

Causation. — In addition to that general dilatation of the heart's 
cavities which has been previously considered, partial dilatations or 
aneurisms are occasionally met with. They have been observed more 
frequently in men than in women, and for the most part at an ad- 
vanced period of life. They are not uncommon, however, during 
middle age, and do indeed occur, though with extreme infrequency, 
in children. 

The occurrence of a localized dilatation must obviously depend on 
comparative feebleness of that portion of the cardiac wall which under- 
goes dilatation, and inability in it to resist successfully the internal 
pressure to which it is subjected. The cause of that weakness is doubt- 
less different in different cases. In some it seems to arise in ulcerative 
destruction of the lining membrane, or in laceration and breaking 
down of more or less of the thickness of the muscular wall ; but in 
most it is apparently due to the presence of one of those forms of en- 
feeblement which have been passed in review, namely, fatty, fibroid, or 
some other variety of degenerative change. It seems obvious, there- 
fore, that it may be a consequence of endocarditis and of myocarditis, 
either in their acute or chronic forms, and of syphilis. Not improba- 
bly also it occasionally originates, as do arterial aneurisms, in the 
effects of very violent muscular exertion or of violence inflicted 
from without. 

Morbid Anatomy. — Cardiac aneurisms now and then occur in the 
right ventricle and even in the left auricle, more especially at the 
foramen ovale; but by far their most common seat is the left ventricle. 
They are generally said chiefly to affect the apex of this cavity ; but 
they may originate at any spot within it. In size they vary from that 
of a pea to that of the heart itself. In form they may be a simple 
hemispherical expansion of the apex or some other part; or flask-like, 



500 



DISEASES OE THE VASCULAR SYSTEM. 



communicating by a comparatively small orifice with the ventricular 
cavity; or sacculated, consisting of a series of intercommunicating 
chambers imbedded in the substance of the walls, and extending over 
a considerable area. Their parietes vary in thickness, and are some- 
times as thin as paper, and generally (especially if the aneurism be of 
large size or old date) consist, in a more or less considerable part of 
their extent, of dense fibroid material, with little or no trace of mus- 
cular tissue. Occasionally they undergo calcification. Cardiac aneu- 
risms are sometimes empty, sometimes contain laminated or other 
forms of coagulum. As regards their results, they seem occasionally, 
after having reached a certain size, to remain stationary, or nearly so ; 
but sometimes they undergo laceration, thus causing communication 
between the left ventricle and one or other of the auricles, or the right 
ventricle or the pericardium. In their progress towards the surface 
they not unfrequently cause pericardial inflammation, and adhesions, 
which both delay rupture and limit its effects. 

Among cardiac aneurisms may be included those of the valves and 
those of the coronary arteries. Valvular aneurisms occur chiefly in 
the aortic and mitral valves, but occasionally in the tricuspid, as the 
result of inflammatory or degenerative weakening or erosion ; and they 
constitute bulgings of various sizes, which, in the case of the aortic 
valve, project into the ventricle, in the case of the mitral into the 
auricle, and usually sooner or later become ruptured and then allow of 
free regurgitation. 

Aneurisms of the coronary arteries are very rare. They are gener- 
ally developed in the trunks, at a short distance from the aorta and 
form small tumors in the transverse sulci ; occasionally numerous small 
aneurisms stud not only the trunks, but also many of the larger 
branches. Like cardiac aneurisms, they may open into the pericar- 
dium, into the cardiac cavities, or into the large vessels at the base of 
the heart. 

Symptoms. — Cardiac aneurisms are often never suspected to be pres- 
ent until the occurrence of rupture causes either grave symptoms of 
cardiac disease, or death from escape of blood into the pericardial cavity. 
There are no special symptoms by which their presence is indicated. 
No doubt they are frequently attended with some of the usual symp- 
toms of chronic heart disease ; and it may be added that, when the 
tumor is large and so situated as to come into relation with the anterior 
thoracic parietes, the presence of a pulsating tumor distinct from the 
heart may occasionally be recognized or suspected. 



EUPTURE OF THE HEART. EFFUSION OF BLOOD 
INTO THE PERICARDIUM. 

Causation and Morbid Anatomy. — Perforation of the muscular walls 
of the heart may be due to accidental or other violence ; with such 
cases, however, the physician has little or nothing to do. Spontaneous 



RUPTURE OF THE HEART. 



501 



rupture is an affection almost exclusively of advanced age ; it sometimes 
occurs in the floor of an aneurism, but more frequently in a circum- 
scribed patch of softening, due to atheromatous disease and obstruction 
of the artery which supplies it; and it is generally immediately trace- 
able to some muscular effort or mental disturbance. Men are more 
liable to it than women. 

Spontaneous rupture occurs almost without exception in the walls of 
the left ventricle. It generally forms in the direction of the muscular 
fibres an irregular rent, or series of rents, which pass irregularly through 
the thickness of the walls, and present considerable differences of size, 
form, and position, on the inner and outer surfaces respectively. The 
lacerated tissue, moreover, is generally infiltrated to a greater or less 
extent with blood. The consequences of laceration of the heart, though 
in all cases ultimately fatal, are liable to variation. In some instances 
(especially in those of cardiac aneurism) the occurrence of rupture is 
preceded by inflammation and the formation of pericardial adhesions ; 
in some the rupture occurs primarily into the connective tissue beneath 
the visceral pericardium ; and in both of these cases the effusion of 
blood is at first circumscribed, and the patient, indeed, may sink, not 
suddenly from copious haemorrhage, but slowly with the symptoms of 
pericarditis. In some instances the rupture occurs directly into the 
pericardial cavity, which then becomes more or less rapidly distended 
with blood. In these cases the pericardium is found post mortem to 
be distended with blood, partly serum, partly a bag of undecolorized 
coagulum in which the heart is inclosed, and by which it is concealed ; 
the heart, moreover, is found empty, flattened, and more or less wrinkled 
on the surface, as if it had been subjected to considerable pressure. 

Symptoms and Progress. — The symptoms of rupture of the heart 
present a good deal of variety. In a large number of cases the patient 
is attacked with severe pain in the region of the heart, gasps for breath, 
faints, and dies in the course of a few minutes, or even a few seconds. 
In some cases he is also attacked with sudden severe cardiac pain, 
faintness, and dyspnoea, but rallies to some extent; and then, passing 
into a condition of extreme collapse, attended with remarkable feeble- 
ness of pulse, coldness of the extremities, profuse perspiration, anxiety 
and restlessness, sighing respiration or extreme dyspnoea, and great op- 
pression, constriction, or pain at the chest, dies at the end of some hours. 
In some cases again (and these are they in which adherent pericardium 
or other circumstances delay or prevent the impletion of the serous 
cavity with blood) the symptoms which mark the occurrence of lacera- 
tion subside, and the patient returns apparently to a state of more or 
less complete health ; upon which, at the end of a few hours, or per- 
haps, a few days, either sudden death occurs from the discharge of blood 
into the pericardium, or pericarditis becomes developed, and sooner or 
later carries him off. 

It need scarcely be said that the phenomena which attend the rup- 
ture of aortic aneurisms into the pericardial cavity are identical with 
those which have just been described. 

Other ruptures of the heart besides those of its outer muscular walls 



502 



DISEASES OF THE VASCULAR SYSTEM. 



may take place ; thus, either the septum of the ventricles or that of the 
auricles may become perforated, the chordae tendinese broken, the aortic, 
mitral, or other valves torn from their attachments or split. The con- 
sequences of these lesions are obvious ; in the first two cases, a more or 
less free communication will be established between the auricles or the 
ventricles ; and in the others regurgitation of blood from the arteries 
into the ventricles, or from the ventricles into the auricles will be estab- 
lished or augmented. The symptoms here will be mainly those of 
aggravated valve disease; and the nature of the accident on which 
they depend may possibly be diagnosed partly by the sudden occurrence 
or the sudden aggravation of the patient's symptoms, partly by the cir- 
cumstances under which this occurrence or aggravation took place, and 
partly by auscultatory signs. 



HYDRO-PERICARDIUM. 

Dropsy of the pericardium is, like hydrothorax or ascites, one of the 
incidents of general dropsy, and in a greater or less degree is of com- 
mon occurrence. The amount of serous fluid which accumulates rarely 
exceeds half a pint, and is often not more than one or two ounces. It 
is insufficient, indeed, as a rule, to cause symptoms or to be discovera- 
ble during life. It is possible, however, that hydro-pericardium, like 
other varieties of dropsy of serous cavities, may become excessive, and 
hence not only embarrass the movements of the heart, but reveal its 
presence by the physical indications (which have been already dis- 
cussed) of accumulation of fluid in the pericardial cavity. When, 
however, the accumulation becomes thus extreme, there is generally 
reason to suspect that it is associated with some degree of pericardial 
inflammation. 

Hydro-pericardium very rarely, if ever, demands special treatment. 
Counter-irritation of the prsecordial region, and the treatment of the 
condition on which the dropsy depends, are the chief measures to be 
adopted. It is conceivable that paracentesis might be needed. 



SYNCOPE. 

Causation. — The aetiology and symptoms of this condition have been 
discussed in an earlier part of this work, to which we refer the reader. 
With reference to the heart's share in its production we may, however, 
make a few additional observations here. The cardiac failure (which 
always takes place to some extent) is commonly referable to causes, 
mental or physical, operating through the nervous system ; the heart 
becomes more or less completely paralyzed, and contracts feebly or not 
at all upon its contents. In some cases, however, its failure to act de- 
pends upon the presence of some mechanical impediment to its action, 



GRAVES'S DISEASE. 



503 



as when it is compressed by rapid serous effusion into the pericardium, 
or by the escape of blood into that cavity, or as when sudden obstruc- 
tion of one of the cardiac orifices by a clot or embolus takes place, or 
the patient is suffering from obstructive valve disease. Hearts enfee- 
bled either by dilatation or by fatty or other forms of degeneration, or 
by abundant or dense pericardial false membranes, are especially liable 
to failure of action, and are necessarily more liable than others to suffer 
under the influence of those causes of failure which have been previ- 
ously enumerated. 

Treatment. — A patient suffering from syncope should be placed in 
the horizontal position, all ligatures should be removed from the neck 
and elsewhere, and he should be freely exposed to cool fresh air. Am- 
monia, or other such stimulants, should be held to the nostrils; ammo- 
nia, ether, or alcohol administered by the mouth • or, if they cannot be 
swallowed, these or turpentine should be given in the form of enemata; 
cold water should be dashed in the face, either from a jug or by means 
of a wetted cloth or towel, and sinapisms applied to the epigastrium and 
to the limbs. If death seems imminent, it is important to promote the 
action of the lungs and heart by frictions, and it may be necessary to 
employ artificial respiration, to stimulate the heart by galvanism, or, if 
the veins be distended, to bleed- from the external jugular vein. If 
syncope be the result of profuse haemorrhage, the question of transfusion 
naturally arises. Whenever the syncopic condition assumes a chronic 
form it is important to maintain the bodily temperature and to prevent 
the patient from making any kind of exertion. Then, too, the gradual 
improvement of the patient's vital powers by the judicious exhibition of 
nourishment, and the assuagement of vomiting and all other symptoms 
which tend to impede this improvement, become objects of the highest 
importance. The value of iron and of other tonics in promoting res- 
toration to health, and of opium or chloral hydrate in remedying sleep- 
lessness, excitement, or delirium need scarcely be insisted upon. 



PALPITATION. GRAVES'S DISEASE. (Exophthalmic Goitre.) 

1. Palpitation. — The phenomena of palpitation, so far as they in- 
volve the heart and vessels only, have been already adverted to. They 
comprise increased frequency of cardiac action, suddenness of impulse, 
together with, not unfrequently, some irregularity or intermission. 

The symptoms which attend palpitation are throbbing of the heart 
and arteries, noises in the ears, muscse, giddiness, faintness, hurried 
respiration, precordial uneasiness and anxiety, flushing of face, cold- 
ness of extremities, clamminess of surface, together with which are often 
associated rushing sounds or murmurs at the cardiac orifices, in the 
course of the larger arteries, and even in the larger veins of the neck. 

The conditions under which palpitation occurs are ver) T numerous. 
Among them may be mentioned mental excitement, excessive bodily 
exertion, indigestion, the influence of certain articles of diet or luxury, 
more especially strong tea, and tobacco ; anaemia and debility, however 



504 



DISEASES OF THE VASCULAR SYSTEM. 



produced ; hysteria, gout ; and, besides these, the presence of actual car- 
diac disease. In man)' of the cases here enumerated the palpitation is 
occasional only, and disappears wholly with the removal of the condi- 
tion on which it depends. In other cases, however, it assumes a chronic 
character ; the heart is then apt to get dilated and hypertrophied, and 
these very changes tend to maintain or aggravate the conditions out of 
which they arose. 

2. Graves's Disease. — Definition. — The most remarkable cases of per- 
sistent palpitation are those described by Graves and Basedow, in 
which, in association with the cardiac palpitation, there is enlargement 
of the thyroid body, with exopthalmos, or protrusion of the eyeballs. 

Causation. — These associated phenomena are most commonly met 
with in young women above the age of puberty ; they are rarely ob- 
served in girls of younger age, and comparatively rarely originate in 
advanced life. Men are affected much less frequently than women, 
The patients are, in some cases, anaemic or hysterical, but by no means 
invariably so. Sometimes the commencement of the disease dates from 
an attack of fever, or is attributed to mental shock or to overexertion. 
Occasionally it ensues on organic lesions of the heart. By some it has 
been contended that the cardiac disturbance precedes and is the cause 
of the goitre and exophthalmos. But against this view (notwithstand- 
ing its plausibility) is the fact that palpitation, more or less long-con- 
tinued, is constantly met with in persons who never have any apparent 
tendency to affection of either the orbit or the thyroid body. Others 
have regarded the goitre as the primary lesion, aud have referred the 
cardiac and other symptoms to its influence, exerted either by pressure 
on the arteries of the neck or in some other less obvious manner. It 
is sufficient, however, in opposition to this view, to point out that 
Graves's disease is sometimes present without thyroid enlargement, and 
that palpitation and exophthalmos are not specially common among 
the goitrous inhabitants of goitrous districts. The proximate cause, 
indeed, of the disease is undoubtedly very obscure. Nevertheless 
there are many circumstances which render it probable that the collec- 
tive symptoms are due to some affection of the sympathetic system, 
which allows of passive dilatation of the vessels of the neck and thy- 
roid body and of those of the orbit, and at the same time of excited action 
of the heart. Many of the symptoms, in fact, are such as closely ac- 
cord with those producible either by paralysis or functional disturbance 
of the sympathetic. Moreover various observers have described, in fatal 
cases of the disease, morbid conditions of the cervical sympathetic. 

Morbid Anatomy r , Symjrtoms and Progress. — The symptoms of Graves's 
disease may come on suddenly or gradually. In the latter case the pa- 
tient probably first complains of violent and frequently repeated cardiac 
palpitation, together with distressing pulsation of the arteries in the 
neck. After these phenomena have existed for a variable period, 
changes are observed in the eyes and in the thyroid body. The affec- 
tion of the eyes, if not actually prior in point of time to that of the 
thyroid body, is generally perceived earlier. At first the change is 
slight, and noticeable only to those whom the patient's healthy aspect 
is familiar. The eyes are a little more prominent, glistening, and star- 



GRAVES'S DISEASE. 



505 



ing than they were. But gradually their prominence becomes more 
and more pronounced until they are so far protruded through the eye- 
lids that these latter are unable to close in sleep, and even at ordinary 
times are so widely separated that the cornea is visibly encircled by the 
sclerotic. Occasionally even the insertions of the recti muscles can 
be clearly distinguished. The protrusion of the eyeballs is generally 
equal on both sides. Occasionally, however, the affection commences 
on one side, and even when both eyes become involved, continues most 
pronounced on one side. It is a curious fact that inflammation rarely 
attacks the insufficiently protected eyeballs; and that sight for the most 
part remains but little affected, excepting, perhaps, that the patient is 
troubled with muscse, becomes long or short sighted, and surfers from 
fatigue in using the eyes. The protrusion of the eyeballs is often to 
some extent variable, increasing under the influence of palpitation, or 
excitement and at the menstrual periods ; and it appears to be due 
either to accumulation in the orbits of fat, or of fat with increase of 
connective tissue, or to dilatation of the vessels, or to all of these con- 
ditions combined in various degrees. It is often attended with aching 
or throbbing in the orbits, and not unfrequently subsides wholly after 
death. 

The enlargement of the thyroid body is for the most part very 
gradual ; and attention is generally first directed to it in consequence 
of the continued presence of pulsation in the lower part of the neck. 
At first it produces merely a slight fulness in the usual situation of the 
gland, but more especially on the right side, and is subject to variations 
in degree ; the enlargement, however, progresses, and ultimately a mani- 
fest tumor results. This may be symmetrical, or may continue a little 
larger on the right than on the left side, and very rarely attains a large 
size, or produces injurious effects by pressure on neighboring parts. 
This form of goitre is generally softer than ordinary goitre, and is often 
attended with a thrill or with distinct pulsation, perceptible to the 
patient as well as to the examiner, and with more or less distinct 
arterial or venous murmur. It has, indeed, been more than once mis- 
taken for aneurism. Its size, like the prominence of the eyes,,is liable 
to variation. 

The condition of the palpitating heart varies somewhat. Its action 
is, for the most part, violent and rapid, its sounds loud and ringing, 
its area of dulness often somewhat increased. At first, no doubt, it is 
in most cases, structurally healthy, and so it may continue. In many 
cases, however, the persistence of palpitation induces more or less hy- 
pertrophy and dilatation, especially of the left ventricle. A functional 
systolic murmur is not unfrequently audible at the base, and murmurs 
are often detectable also in the arteries and veins of the neck. Occa- 
sionally, as has been already intimated, the phenomena of Graves's 
disease supervene on actual cardiac disease ; and it may be added that, 
in most cases in which post-mortem examinations have been made, 
more or less atheromatous change has been detected in the arterial 
system. 

The phenomena which have been hitherto described are not the only 
ones that are commonly presented in the course of this affection. It 



506 



DISEASES OF THE VASCULAR SYSTEM. 



has especially been observed that the patient is peculiarly liable to be- 
come irritable, fretful, peevish, incapable of application, and to suffer 
from sleeplessness ; that her appetite is capricious, often voracious ; 
that she suffers from flatulence, and at one time from constipation, at 
another from diarrhoea; that there is a tendency to febrile excitement, 
with elevation of temperature by one or two degrees, and that this con- 
dition may be associated with the presence of Trousseau's "cerebral 
macula ;" and that there is generally amenorrheea, and not unfrequently 
leucorrhcea. Anemia and cachexia are also sometimes present. In some 
cases enlargement of the spleen has been observed ; and in some enlarge- 
ment of the mammge. 

It should be added that, in the early stage of Graves's disease, palpi- 
tation, with throbbing of the vessels in the neck, may be present without 
obvious thyroid-gland or eye affection, and that in some cases the goitre, 
in some the exophthalmos, may never become developed. 

Graves's disease is not usually dangerous to life. Occasionally 
patients entirely recover; more commonly there is partial amendment 
only ; and in a large number of cases the disease is slowly progressive, 
and at best after awhile becomes stationary. When death takes place 
it is usually the consequence of some intercurrent affection, more especi- 
ally some affection of the lungs. In rare cases the thyroidal tumor 
causes death by pressure on the trachea. 

Treatment. — There is considerable difference of opinion as to the 
treatment of this disease. Some recommend, Trousseau condemns, the 
use of iodine. Iron is generally strongly advocated ; both Trousseau 
and Von Grafe, on the other hand, regard it as injurious. Depletory 
measures, and even the removal of blood, have been lauded. Digitalis 
in largish and frequent doses is said to be exceedingly valuable in pro- 
moting contraction of the dilated and pulsatile vessels, and in thus 
relieving and curing the disease. On the same principle ergot of rye 
or lead may be supposed to be indicated. Belladonna again seems to 
act beneficially. Cold applications to the thyroid body and to the 
precordial region are said to be very serviceable. If the patient be 
anaemic, or suffer from amenorrhoea, or want of sleep, or from any other 
condition calculated to cause or to maintain ill-health, special treatment 
will of course be needed. 



CARDIAC NEURALGIA. ANGINA PECTORIS. 

Causation. — The causes which induce cardiac neuralgia are numerous, 
but for the most part such as affect the circulation either through the 
nervous system or by muscular exertion. Among them are — mental 
excitement, such as anger, or any sudden impression of pain or pleas- 
ure, and the like; intemperance in eating or drinking; active exer- 
cise, especially ascending a hill or staircase, and straining at stool ; in 
some cases even a blast of cold air. The attacks are often brought on, 
indeed, by mere walking exercise, and not unfrequently they occur 
during sleep. Cardiac neuralgia is of frequent occurrence in the course 



ANGINA PECTORIS. 



507 



of heart disease, and in cases of aortic aneurism, and under these con- 
ditions may be met with at any age and in either sex. 

Pathology, Symptoms, and Progress. — Neuralgic pain, commencing 
in the heart, and radiating thence, presents remarkable features. It 
affects primarily and mainly the precordial region, being situated 
therefore chiefly to the left of the sternum, but sometimes involving 
the sternal and right mammary regions as well. It varies in severity, 
is aching, burning, or indescribable, but generally attended with a 
marked sense of constriction, dread of breathing deeply, and anxiety. 
It may radiate down into the lower part of the abdomen, up into the 
root of the neck, and backwards to the spine; but is specially charac- 
terized by tendency to extension to the left shoulder, and thence down- 
wards along the inner side of the upper arm to the elbow. Not unfre- 
quently it spreads to both shoulders, thence to both elbows, and thence 
again to the wrists, and even to the tips of the fingers. Occasionally 
it similarly involves the lower extremities. The abnormal sensation 
which extends along the arms and lower limbs is sometimes an aching, 
sometimes a sense of tightness or constriction, sometimes a tingling, 
and not unfrequently a mere numbness. In connection with these 
symptoms, the affected limbs, as also the face, become suddenly pale 
and cold ; to which conditions venous congestion and, more or less, 
clammy perspiration are apt presently to succeed. During the height 
of the attack the patient often becomes giddy and faint, and sometimes 
falls into a state of insensibility, which may be attended with convul- 
sions. 

Attacks of cardiac neuralgia vary in their intensity, in their dura- 
tion, in the frequency of their recurrence, and in the conditions under 
which they occur. They may be so slight as to consist in nothing more 
than a momentary pain or uneasiness in the region of the heart, together 
with some extension of uneasiness to one or both shoulders. They may 
be so severe that the patient suffers, and has the appearance of suffering, 
indescribable agony, with the overpowering dread of impending death. 
He suddenly becomes still, fearing even to breathe, clutches whatever 
is near him for support; or, assuming some strange attitude which ex- 
perience has taught him, he grovels on all fours, or lies upon his chest, 
or sits astride a chair with his face to the back, and his head bent over 
it. The attacks may last from a few seconds to many hours. In the 
latter case, however, their continuance is due to the repetition of par- 
oxysms which are for the most part of no great intensity. Some- 
times a patient has one attack only, or he has a succession of attacks 
at various intervals, and then no more ; sometimes the first is fatal ; 
more commonly the affection commences comparatively slightly, with 
attacks succeeding one another at long intervals, but gradually the 
intervals become shorter and the attacks more severe, and tend to recur 
on slighter and slighter provocation. 

When cardiac neuralgia occurs independently of distinct cardiac 
lesion, it has received the name of " angina pectoris." Angina pectoris 
is rarely met with below the age of forty or fifty, and is far more com- 
mon in men than in women. In the majority of cases, too, it has a 
marked tendency to recur at gradually shortening intervals and with 



508 



DISEASES OF THE VASCULAR SYSTEM. 



increasing severity, and sooner or later to prove fatal. Occasionally, 
however, the disease manifests itself in young persons ; and occasion- 
ally also (and more particularly in these latter cases) complete recovery 
sooner or later takes place. After death from angina pectoris, various 
lesions have been detected, and have been regarded as its cause; the, 
more important of them are calcification of the coronary vessels, and 
fatty and other degenerative affections of the muscular tissue of the 
heart. In other cases, on the other hand, the heart has been found to 
be perfectly healthy. But it is obvious that such lesions as are here 
adverted to can only act, if they act at all, as predisposing causes. 
"What, then, is the proximate cause? It has been assumed to be spasm 
or cramp of the muscular tissue of the heart ; and in favor of this 
view it may be observed how intense often is the agony which is pro- 
duced by the spasmodic action of the bowels, or uterus, to say nothing 
of that of the voluntary muscles. The character of the pulse has been 
described as being sometimes weak and scarcely perceptible; at others, 
slow, full, and strong. There is reason, however, to believe, both from 
the pallor and coldness of surface which attend the onset of the attack, 
as well as from sphygmographic observation, that an essential feature 
of the disease is sudden and extreme contraction of the systemic arteries, 
which both prevents the free passage of blood to the capillaries, and, 
damming it up, as it were, in the heart, excites that organ to unwonted 
but more or less fruitless efforts. 

Treatment. — The treatment of cardiac neuralgia, or angina pectoris, 
must be partly prophylactic, partly directed to the relief of the spas- 
modic attacks. It is of the greatest importance that the patient should 
avoid or obviate all those conditions which are apt to produce the 
affection ; that he should eschew 7 all mental and bodily exertion or 
fatigue; and that indigestion and all other functional derangements 
should be as far as possible prevented by careful attention to diet and 
appropriate remedial measures. For the treatment of the anginal 
attack, various remedies have been suggested. Among the most valu- 
able are the diffusible stimulants — ammonia, ether, and brandy — and 
narcotics, such as opium and belladonna. During an attack, diffusible 
stimulants are probably the most useful. Faradization to the cardiac 
region has been attended with good results. Dr. Bruuton, guided by 
the fact of the spasmodic contraction of the arteries which attends, if it 
do not cause, angina, has tried the inhalation of nitrite of amyl (which 
relaxes the muscular wails of these vessels) during the paroxysm with 
striking benefit. He applies five or six drops to the nostrils on a rag 
or piece of blotting-paper. This method has been subsequently em- 
ployed by other observers with marked success. 



CYANOSIS AND MALFORMATIONS. 

Cyanosis. 

Causation. — Lividity or blueness of the skin is a frequent symptom 
of those diseases or conditions in which the due aeration of the blood 



CYANOSIS. 



509 



is interfered with, and especially, therefore, of some forms of lung and 
of some forms of heart disease. It may be met with, consequently, in 
all cases in which impediment exists to the passage of air along the 
larynx or trachea; in all cases also in which there is obstructive disease 
of the bronchial tubes, whether it be bronchitis or any other affection ; 
and in all cases in which, whether from emphysema or other organic 
lesions, from pulmonary congestion or oedema, the free transmission of 
blood along the pulmonary capillaries, or the free admission of air into 
the air-cells is interfered with. It is a striking characteristic of 
cholera ; in which disease, either from alteration in the blood or from 
contraction of the smaller branches of the pulmonary artery, the blood 
ceases to pass in quantity through the pulmonary capillaries. Lastly, 
it is very frequently observed in cases of heart disease, more especially 
of disease of the right side, and in cases of congenital malformation. 

Symptoms and Progress. — It is in the last class of cases, indeed, 
that the condition commonly known as cyanosis is most frequently 
present — cases in which the blueness first manifests itself at birth, or 
within a few weeks, a few months, or very rarely a few years after that 
event. We will describe it as it presents itself in these cases. The 
blueness of surface varies in depth, but is always most pronounced in 
the cheeks, lips, and tongue, and in the extremities of the fingers and 
toes. Here the natural rosy hue may merely present the slightest 
possible inclination towards purple, or the parts may be purple, blue, 
or almost black. The general surface is dusky, or livid and ghastly. 
The color varies from time to time; it becomes intensified on exertion, 
or mental excitement, or exposure to cold, or under the influence of 
catarrhal or other like affections of the respiratory organs ; and in some 
cases it almost entirely subsides during times of comparatively good 
health and perfect quiescence. The conjunctivse are mostly congested, 
(Edematous, and glistening; the lips, and perhaps the nose and eyelids, 
are tumid, but the most remarkable degree of tumefaction is always 
manifested by the terminal phalanges of the fingers and toes, which 
become strikingly thickened and enlarged, or bulbous. The circula- 
tion is feeble, the surface (especially that of the extremities) generally 
cold, and the patient disinclined, and, indeed, unable, to engage in 
active exercise. He is liable to paroxysmal attacks of difficulty of 
breathing, during which his cyanosis increases, and he not unfrequently 
passes into a state of syncope ; and he is very apt to suffer from con- 
gestive and inflammatory affections of the respiratory organs. He is 
generally sluggish, both in body and in mind, and his temper is for the 
most part irritable and fretful. Dr. Peacock asserts that the internal 
temperature of cyanotic patients is not below that of healthy persons. 

Pathology. — It was not unnatural to assume that the cyanosis of mal- 
formation is due to the admixture of arterial and venous blood, which 
takes place in the great majority of these cases, through either an in- 
complete ventricular septum, a patent foramen ovale, or a persistent 
ductus arteriosus. But cyanosis has been proved to exist in an intense 
form in cases of malformation where no such admixture was possible, 
and to be absent from many cases of malformation in which the com- 
munication between the venous and arterial sides of the heart was un- 



510 



DISEASES OF THE VASCULAR SYSTEM. 



usually free. We are hence driven to the conclusion that cyanosis must 
in the main be due to the same causes which determine lividity in other 
forms of heart disease, namely, impeded transmission of blood through 
the lungs, and consequently insufficient aeration, and overaccumulation 
of blood in the systemic veins. If this be the true explanation, it may 
fairly be asked what are the distinctive marks by which typical cyanosis 
is distinguishable from ordinary cardiac lividity? And it must be ac- 
knowledged that the differences are of degree or detail only, and are 
probably due to the fact that the veins of young children more readily 
yield under the continued strain to which they may be exposed than do 
those of adults. Cardiac lividity in adults never attains that depth of 
color which we often meet with in cyanotic children ; and the bulbous 
enlargement of the fingers and toes which is so common in the latter 
case is rarely observed as a consequence of acquired heart disease. 

Malformations. 

Causation and Morbid Anatomy. — The subject of cardiac malforma- 
tions is one of great interest and extent, and impossible of adequate 
discussion in a work like the present. Yet it cannot be wholly ignored; 
we proceed, therefore, to make a few remarks upon it. 

The auricles form originally a single cavity, and the separation 
between them is effected by the development of a vertical septum, of 
which the fossa ovalis represents the last-formed portion. The septum 
may be wholly absent; or the fossa ovalis may alone remain more or 
less patent, as it is at birth; and between these extremes every degree 
of defect may be observed. The ventricles, also, constitute, in the first 
instance, one cavity, which, in the course of development, becomes 
divided into two by the growth of a partition from the apex of the 
organ upwards, the last-formed part being therefore that which lies 
below the arterial orifices. This septum also may be wholly or in part 
absent; in the latter event the deficiency is almost always found imme- 
diately below the valves. The bulbus arteriosus, again, is in the first 
stage of development a single cavity, continuous with that of the com- 
mon ventricle, and becomes like, that by the growth of an independent 
septum, divided into two portions, of which one becomes the aorta, the 
other the pulmonary artery. It is possible for this separation never to 
be completed ; it is possible that one of the arteries may be imperfectly 
developed or become impervious; it is possible also for them to be 
transposed, so that the pulmonary artery becomes continuous with the 
left ventricle, the aorta with the right, Further the ductus arteriosus, 
which is patent up to the time of birth, and which allows the aortic 
blood to be distributed freely to the branches of the pulmonary artery, 
may remain patent. Various valvular defects, for the most part causing 
obstruction, are also of frequent occurrence. Lastly, many of these 
malformations may coexist, and indeed the appearance of one defect in 
the course of development usually necessitates the supervention of others 
at a later period. 

Defect of either the ventricular or auricular septum to a slight extent 
does not necessarily allow of any material admixture of venous and 



MALFORMATIONS OF THE HEART. 



511 



arterial blood, or involve discomfort or danger to life; if, however, such 
communication be free, the aerated and non-aerated blood-streams be- 
come more or less considerably commingled, and serious symptoms 
result. It is obvious that similar consequences will ensue, in a more 
or less aggravated form, under various other circumstances; as, for 
example, when the tricuspid orifice is contracted or obliterated, and all 
the blood that enters the right auricle has consequently to pass through 
the foramen ovale into the left auricle, and thence into the left, or it 
may be common ventricle, previous to its distribution; or when, owing 
to relative displacement of an imperfect septum ventriculorum and of 
the orifices of the pulmonary artery and aorta, both vessels seem to 
spring from the right ventricle; or when (assuming also the septum of 
the ventricle to be incomplete) the aorta or the pulmonary artery is con- 
tracted or impervious, and in the one case the pulmonic circulation is 
affected from the aorta through the medium of the ductus arteriosus, in 
the other the systemic circulation is maintained through the channel 
afforded by the trunk of the pulmonary artery and the ductus arteriosus 
between the heart and the descending arch of the aorta. 

Symptoms and Progi*ess. — In the various forms of malformation 
which have here been passed in review, there is very often some dis- 
proportion in point of size between the ventricles, and some hypertro- 
phy of their muscular parietes, consequently there is generally during 
life some increase of precordial dulness, some modification of its form, 
and some increase in the area and force of the cardiac pulsations. 
Further, there is, in a large number of cases, a more or less loud and 
rough systolic murmur, audible with greatest distinctness over the left 
third costal cartilage, or somewhere between this point and the left 
nipple, and, according to its degree of intensity, audible over a restricted 
area only, or over the whole precordial region and beyond it. 

The general symptoms which attend malformations of the heart are 
(if certain valves only be affected) those mainly of obstructive disease 
of those valves; if, however, in addition to valvular obstruction, there 
be other congenital defects, or if, independently of valvular lesions, 
those other defects are sufficiently serious to cause symptoms, the 
patient presents in a more or less aggravated form the phenomena 
which have been described under the head of cyanosis. 

The prospects of life in children born with malformed heart are 
very gloomy. The great majority die in the first few weeks after 
birth. A small proportion of them survive up to the period of puberty. 
Very few T , however, who are markedly cyanotic, attain adult life. The 
chief causes of death, according to Dr. Peacock, are cerebral disturb- 
ance resulting from defective aeration of the blood and congestion of 
the brain, and imperfect expansion, collapse, and engorgement of the 
lungs. 

Treatment. — The treatment of cases of malformation should be mainly 
hygienic and prophylactic. Patients should be protected by warm 
clothing against vicissitudes of temperature, debarred from all active 
bodily exercise and mental excitement, and sustained by nourishing 
diet. Their digestive organs and emunctories should be maintained as 
far as possible in a healthy condition. 



512 



DISEASES OF THE VASCULAR SYSTEM. 



1 



(2.)— DISEASES OF THE ARTERIES. 
ARTERITIS. 

1. Periarteritis. Causation and Morbid Anatomy.— The outer tunic 
of the arteries, and to some extent the middle and even the internal 
tunics, may be regarded as merely modified portions of the general 
connective tissue. They are directly continuous with it, and, as might 
be supposed, readily share in its diseases. Hence, when a district of 
the body is in a state of inflammation, the walls of the arteries which 
are comprised within it also become inflamed, and occasionally, indeed, 
inflammation may attack these more violently than other parts, and 
may travel along them far beyond the limits of the primarily affected 
area. Such inflammation is usually limited to the outer tunic, and 
involves the others (if at all) comparatively late and to a slight degree. 
It is characterized by congestion, infiltration, and thickening of the 
affected parts, is sometimes attended with the development of pus in 
and around the outer arterial coat, and occasionally with ulcerative 
destruction or necrosis of the middle and inner coats, and consequent 
perforation. From the very slight extent in which usually the internal 
coat is implicated, it but rarely happens that the lining membrane loses 
its polish, or that thrombosis takes place. 

The symptoms to which this form of arteritis gives rise are, more or 
less pain and tenderness along the affected vessel, more or less hardness 
and induration in its course, and some degree of inflammatory fever. 
The formation of abscesses, the plugging of the artery and its perfora- 
tion, would severally produce special symptoms. These, however, are 
matters which will be more conveniently discussed hereafter. 

2. Endoarteritis. Causation and Morbid, Anatomy. — But, besides 
that form of inflammation which commences from without, we not 
unfrequently meet with inflammation which originates in the lining 
membrane, and tends to remain limited to that membrane, or at least 
involves the outer coats gradually and by simple extension only. 

The causes of primary endoarteritis are somewhat obscure. In 
some cases it is due to the irritation of a thrombus or impacted em- 
bolus, in some to the effect of long-sustained excesssive blood-pressure 
(as in Bright's disease), or to the continued violence of the impact of 
the blood-stream on certain points. It appears, too, in many cases, to 
depend on cachectic conditions of the system, referable to long-con- 
tinued exposure, deficiency of food, intemperance, syphilis, and the 
like. Indeed, it may be asserted that syphilitic disease of arteries is, 
at least in many cases, scarcely, if at all, distinguishable from endoar- 
teritis. 

Endoarteritis of the larger vessels is indicated by the development 
in the substance of the internal coat of translucent wheal-like thicken- 
ings which project to a greater or less extent into the vascular channel. 
They have rounded or irregular margins, and often coalesce so as to 
form patches of considerable extent, which then present nodulated sur- 



DEGENERATION OF ARTERIES. 



513 



faces. They may be scattered singly, in small numbers, or may involve 
large tracts of surface, rendering the vessels remarkably uneven, and they 
are particularly apt to appear at the points of bifurcation of vessels, or 
at the points of junction of branches with the trunks from which they 
spring. When the affection is the consequence of thrombosis, and when 
it occurs in minute arteries, it often causes uniform thickening of con- 
siderable superficial extent. The thickening is due to inflammatory 
proliferation of the protoplasmic elements of the internal arterial tunic, 
and it may be observed that, according to Cornil and Ranvier, the 
acute form of the disease is distinguishable from the chronic by the 
fact that in it the proliferation begins at the surface, which is conse- 
quently rendered rough, while in the latter it takes place chiefly in the 
substance of the tunic. Generally, after awhile, the muscular coat 
loses its contractile power, and when the inflammation involves the 
whole thickness of the vessel, the walls become generally thick and 
translucent. 

Symptoms. — Endoarteritis may, as has been hinted, be acute or 
chronic, but there are no special symptoms by which its acuteness or 
chronicity can be distinguished ; and, indeed, endoarteritis becomes 
chiefly important and distinguishable by the consequences, mainly 
mechanical, to which it leads. These (which will be elsewhere more 
fully considered) are referable to irregularity, rigidity, degeneration, 
and weakening of the arterial walls, diminution or occlusion of the 
channel, dilatation or aneurism, ulceration and rupture; to which may 
be added the consequence of the deposition of fibrin upon the rough- 
ened surface, and of the formation of granulations or of pendulous 
fibrinous polypi. When endoarteritis occurs in superficial arteries in 
consequence of thrombosis or embolism, considerable pain and tender- 
ness are experienced in the course of the affected vessel. It follows, 
therefore, that pain may be a symptom of the endoarteritis of deep- 
seated vessels. 



DEGENERATION OF ARTERIES. 

Causation and Morbid Anatomy. — Primary fatty degeneration of 
arteries is not of unfrequent occurrence with the advance of years. It 
is recognized by the presence of irregular opaque yellowish spots, 
apparently in the substance of the internal membrane, which may be 
sparsely scattered, or so abundant as to produce a general mottling. 
But although this affection commences in the internal coat, it soon 
involves the middle coat to a greater or less extent. Microscopically 
it is found that the cells of the inner coat, and before long those of the 
middle as well, are the seat of more or less abundant fatty deposit. 
They gradually become entirely destroyed, and with the progress of 
the disease the intervening tissues, including the elastic elements and 
the muscular fibres, undergo disintegration. 

But more frequently fatty degeneration constitutes a late stage of 
endoarteritis. The translucent or cartilage-like nodules become more 

33 



514 



DISEASES OF THE VASCULAR SYSTEM. 



or less opaque, generally in their interior, owing to the fatty trans- 
formation of the cells of which they are in so large a degree composed. 
And after awhile the interior of the growth may break down into an 
opaque pulp, containing abundant fatty molecules, degenerate remnants 
of tissue, and cholesterin. A small abscess-like cavity is the result. 
Or, as in the former case, the fatty degeneration may commence super- 
ficially and thence gradually invade the whole of the diseased patch. 

Whether the degeneration be primary, or secondary to arteritis, 
there is a tendency after awhile for the degenerated structures to break 
down and to be discharged into the vascular channel. When the dis- 
integration begins superficially, the affected surface becomes eroded, 
and an ulcer-like cavity results. When, on the other hand, the soft- 
ening mass is separated from the blood-stream by a layer of still 
coherent tissue, perforation after awhile takes place in this latter, and 
the escape of the detritus through the orifice results in the formation 
in the substance of the arterial walls of a flask-like cavity, which 
maintains a free communication with the arterial channel. 

But fatty degeneration is not the only degenerative change which 
occurs. In a large number of cases, more especially chronic cases or 
those of persons advanced in years, the precipitation of calcareous mat- 
ter accompanies the fatty process. Calcareous molecules are deposited 
in the tissues which intervene between the fattily degenerating cells; 
and the result may be the formation either of amorphous tuberculated 
calcareous lumps, or more frequently of thin, more or less transparent 
plates, which are curved in conformity with the curvature of the vessel, 
and which, though usually covered in the first instance by a thin 
membranous lamella, soon become denuded. Further, they tend to 
become detached at the margins, and after a time to separate wholly or 
in part, and to leave ulcer-like excavations behind. Calcareous plates 
may be scattered irregularly and in small numbers, or may be so 
numerous and large as to render the vessel in which they occur a rigid 
bone-like cylinder. 

There is yet another form of calcareous degeneration which is occa- 
sionally met with in arteries of medium and small size. It is not 
attended with, or consecutive to, fatty degeneration, but is due to cal- 
careous transformation of the muscular cells of the middle coat. The 
capillary arteries occasionally undergo complete conversion into calca- 
reous cylinders. 

The degenerative processes above described, although for the most 
part originating in, and mainly implicating, the internal coat, tend 
sooner or later to involve the middle coat also; and, even if this pre- 
sent no visible structural change, it becomes more or less impaired as 
to contractile power and capability of resistance. It may be added 
that, with certain exceptions which have been specified, they affect the 
aorta (especially its arch) far more frequently than they affect other 
vessels. Yet none enjoys immunity. The pulmonary artery, however, 
is comparatively rarely affected. 

Symptoms. — The presence of arterial degeneration cannot always be 
recognized with certainty. It causes rigidity and therefore loss both 
of elasticity and of contractile power. If superficial vessels be inipli- 



ANEURISM. 515 

cated their condition may often be readily recognized by the finger ; 
if the larger and deeper-seated trunks be involved the loss of their 
elasticity renders the systolic throb of the pulse prolonged and its 
cessation sudden ; and, further, this same loss of elasticity adds to the 
resistance which the heart has to overcome, and tends to induce hyper- 
trophy of that organ. The more serious and striking consequences of 
arterial degeneration are the same as have already been adverted to in 
connection with arteritis, and will be best discussed under subsequent 
"headings. 



ANEURISM. [Dilatation of the Arteries.) 

The terms dilatation and aneurism are of common use as applied to 
diseased arteries. By dilatation we generally mean, either a uniform 
or a somewhat uneven enlargement of the channel of some considerable 
length of vessel ; by aneurism a comparatively abrupt enlargement of 
a more circumscribed tract. The term aneurism is, however, also ap- 
plied to certain tumors which consist of bundles or convolutions of 
simply dilated arteries. 

Causation, — Aneurisms, in the more restricted sense of the word, 
are bulgings caused by the pressure of the blood within vessels on 
walls which have been weakened either by the effects of accidental or 
other injury, or by the progress of the degenerative changes which 
have just been considered. The pressure which the blood within the 
arteries ordinarily exercises on their walls is amply sufficient to cause 
bulging and aneurism at points in which the resisting power of the 
vessels is impaired. It need scarcely be added that when that pressure 
is greatly increased, as it is habitually in Bright's disease, and inter- 
mittently in violent muscular efforts, its effect on diseased arteries is 
necessarily proportionately augmented ; and indeed under some such 
conditions tracts of even healthy arteries may undergo considerable 
and permanent dilatation. The influence of violence in the production 
of aneurism is very important, whether we regard it as acting through 
the medium of the blood pressure, or directly on the vessels by strain. 
Its importance is shown by the frequency with which aneurisms occur 
in those vessels which from their situation are specially exposed to vio- 
lence, the frequency with which they occur in those persons whose 
avocations demand excessive muscular exertion, and the frequency also 
with which the origin of aneurisms is distinctly traced back to some 
unwonted effort, or to some personal injury. The starting-point of 
the aneurism is then some laceration, probably of the middle coat of 
the artery, or, if the vessel be already diseased, some injury to the 
degenerated tissue. But in the great majority of cases the aneurism 
commences in a region already diseased, and probably independently 
of any undue pressure. The passive and enfeebled wall slowly yields 
before the dilating force to which it is subjected. The surface left by 
the erosion of an atheromatous patch, or by the detachment of a cal- 
careous plate, or the cavity produced by the discharge of a quantity 



516 



DISEASES OF THE VASCULAR SYSTEM. 



of atheromatous detritus through a minute orifice are all of them fre- : 
quent sites of commencing aneurism. But mere atheromatous change, 
apart from actual removal of tissue, especially if the middle coat be 
involved, will alone cause sufficient enfeeblement to allow of aneurismal 
expansion. 

Aneurism is a far more common affection in males than in females, 
mainly on account of their different avocations, and it belongs almost 
exclusively to adult life. It is mainly indeed a disease of advanced 
years ; still it not unfrequently occurs both in men and women, be- 
tween the ages of 30 and 40, especially in those who have led 
debauched or hard lives, and have suffered from those conditions 
which produce endoarteritis. 

Morbid Anatomy. — Many needless refinements have been made in 
respect of the classification of aneurisms. We shall not waste time 
upon this subject, but will describe them with reference (1) to their 
form and size; (2) to the constitution of their walls; and (3) to the 
nature of their contents. 

1. Aneurisms in some cases are mere globose or fusiform dilatations 
of some limited length of artery in its whole circumference. Much 
more frequently they are thimble-shaped or flask-like bulgings, which 
involve the vessel in a portion only of its periphery. In this latter 
case the orifices by which they communicate with the artery vary 
greatly in size relatively to the aneurismal tumors, are round or oval 
(with the long diameter corresponding to the axis of the vessel), and 
present more or less tumid margins, which in large aneurisms, involv- 
ing nearly the whole width of an artery, are distinctly developed above 
and below only. In other cases aneurisms present great irregularity 
of form. This may be due to the fact that several aneurismal bulg- 
ings have taken place within a short distance of one another, and have 
coalesced during their progressive enlargement ; or to the fact that the j 
walls of the primary aneurismal sac have yielded unequally ; or to the 
fact that they have ruptured or been destroyed at certain points, and i 
that the blood has consequently escaped into fresh cavities by lacera- j 
tion, which form diverticula from the original aneurism, and remain 
henceforth portions of it. It must be added that the configuration 
of aneurisms is also greatly determined by the nature, arrangement, 
and resisting power of the structures which surround them and oppose 
their extension. The size which aneurisms attain depends in some i 
degree on that of the arteries from which they spring. Aneurisms 
of the cerebral arteries are rarely larger than a walnut, while those of ! 
the aorta may vary from the size of a pea to that of a cocoanut or a 
child's head. 

2. Occasionally the walls of an aneurism comprise all the arterial 
tunics in a fairly healthy condition. This may be the case in fusiform 
or globose aneurisms due to general dilatation of a certain length of 
artery. In the great majority of cases, however, the condition of 
things is different. The lining membrane of the artery may be traced, 
often somewhat thickened and pulpy, over the lips of the aneurismal 
orifice, and thence with more or less distinctness over the whole inner 
surface of the aneurism. The external coat of the artery may also be 



ANEURISM. 



517 



traced from without over the whole extent of the aneurismal tumor. 
And as regards the middle coat, this may in small aneurisms often be 
I recognized in a more or less attenuated state throughout their whole 
extent ; and in larger ones may often be followed for some little dis- 
I tance from their origin onwards, and traces of it may still be detected 
' scattered here and there throughout the rest of their circumference. 
Occasionally the middle arterial tunic stops short around the aneuris- 
mal orifice. Even when an aneurism commences with perforation of 
the lining membrane of the artery, an adventitious lining forms before 
long, and becomes continuous with that of the artery. And indeed it is 
obvious that in all large aneurisms the laminre which correspond to 
the inner and outer arterial tunics and are continuous with them, are 
mainly, if not entirely, of new formation. Further, these two coats 
become, in the course of time, identical in structure, and blend, inclos- 
sing within them any remnants there may still be of the middle coat. 
Not unfrequently also they become the seat of fatty or calcareous 
changes. As an aneurism extends surrounding organs and tissues be- 
come involved in it, and take a share in the formation of its walls, the 
proper coats at the same time disappearing to a greater or less extent. 

3. An aneurismal cavity sometimes remains perfectly free from clot, 
sometimes, on the other hand, becomes in a greater or lesser degree 
obliterated by its slow deposition. The local conditions which favor 
the formation of clots are roughness of surface and comparative stag- 
nation of blood. Both are usually present in perfection in aneurisms 
which are primarily due to circumscribed bulging of an artery, and in 
which the orifice of communication is comparatively small. In these 
the process commences by the deposition of a thin adherent film of 
coagulum upon the surface of the lining membrane. To this other 
films are added in slow succession ; and hence gradually the resulting 
mass of coagulum assumes a laminated or stratified character. This 
process may in fortunate cases go on until the cavity is obliterated, the 
last formed laminae of coagulum forming a kind of irregular bar or 
septum across its mouth. More frequently, however, the aneurism is 
obliterated in part only, the coagulum being indeed often limited to 
some diverticulum. When the lining membrane of an aneurism is 
fairly uniform and smooth, and the orifice large in relation to the 
cavity, there is often no attempt whatever at coagulation. And fusi- 
form aneurisms, or aneurisms due to general dilatation, always remain 
free, or at all events never present more than such patches of clot as 
may be met with in an undilated aorta, of w T hich the surface is studded 
with patches of atheroma or calcareous plates. 

The origin of aneurisms in blood pressure which the arterial walls 
are incompetent effectually to resist has already been considered. Their 
progressive enlargement is dependent on the continued operation of the 
same cause. In accordance with a w T ell-know r n hydrostatic law, the 
force which the blood exerts on a given aneurismal area is exactly 
equal to that which it exerts on an equal area of the artery in its 
neighborhood ; or, in other words, the total pressure on the inner sur- 
face of an aneurism is in exact proportion to the superficial extent of 
that surface, and has no relation whatever either with the size of the 



518 



DISEASES OF THE VASCULAR SYSTEM. 



orifice or the form of the aneurism. It follows consequently that the 
larger an aneurism grows, the less capable its walls become of success- 
fully opposing the blood-pressure within, unless they undergo some j 
kind of compensative increase of strength. This, however, does not I 
necessarily or even commonly occur. 

The effects of aneurisms on the organs in their viciuity are in the 
main those of pressure, and will necessarily therefore vary in impor- 
tance and in kind according to the situation in which the aneurism 
is developed. When an aneurism forms among easily-displaceable 
organs it may attain considerable size without causing any special mis- 
chief or uneasiness. In all cases, however, surrounding parts, sooner 
or later, become pressed upon ; if they are unyielding they are grad- 
ually destroyed ; if yielding they first yield, and are only at a compar- 
atively late period involved in the aneurismal parietes, and undergo 
the same fate as that to which the unyielding tissues more readily sue- ( 
cumb. Thus bones and cartilages become gradually eroded, and their 
eroded surfaces, first exposed in the walls of the aneurism, presently 
stand out from them into the interior of the cavity. Muscular and 
other soft tissues are first displaced, then flattened and compressed or 
stretched, and finally incorporated in the advancing wall and lost. 
Nerves and veins are similarly treated — pressure on the former causing 
pain or spasm, or other functional disturbance, and then paralysis or 
anaesthesia; pressure on veins causing impediment to circulation, with 
subsequent congestion and dropsy. Similar effects of pressure may be 
exerted on the trachea, the oesophagus, the intestines, and even upon 
the brain, lungs, and liver, and other solid organs, and in each case with 
the production of special symptoms, which we need not stop to discuss. ! 

The results of aneurisms, unless a cure be effected by surgical pro- 
cedure, are, in the great majority of cases, unfavorable. In a small 
proportion the cure takes place by the spontaneous filling of the cavity 
with laminated clot ; but generally the tumor continues to enlarge and 
after a time causes death by implicating some important organ ; or by 
perforation and consequent profuse discharge of blood. The latter event | 
may take place into one of the serous cavities, in which case the actual 
opening is usually caused by laceration ; or it may take place at the | 
cutaneous surface, or into one of the mucous canals, when perforation 
is due either to ulceration or to the separation of an eschar. Rupture 
or perforation may also take place into the cerebral or spinal cavities, 
into the veins, and even into the heart itself. 

Symptoms and Progress. — The symptoms by which an aneurism may 
be recognized are: first, those which are due to it as a simple tumor; 
and second, those which depend on its relations with other parts. An I 
aneurism usually is a pulsating tumor. If it be empty of clot its pulsa- 
tion is expansive like that of the arteries, and if it can be grasped the 
fingers which inclose it will be sensibly separated at each expansion. 
If it be full of clot no such expansion occurs ; and if pulsation be then 
felt it is merely such pulsation as may be presented by any other solid 
tumor abutting on an artery : the aneurism simply follows the move- 
ments of the subjacent vessel. It is important to know that the mere 
imparted pulsation of a rounded tumor may easily be mistaken for ex- 



ANEURISM. 



519 



pansive pulsation unless the tumor be grasped at its widest part; inas- 
much as if it be grasped in some narrower and more superficial zone 
the alternate rise and retreat of the skin-covered wedge-like body be- 
tween the fingers exactly produces that same periodical and measured 
separation of them which is so characteristic of true pulsation. The 
comparative hardness, however, of such a mass, and the probable fact 
that it may admit of removal from the influence of the subjacent artery, 
will generally correct any erroneous impression. The pulsation of an 
aneurism is sometime vibratile, especially if it be situated in the neigh- 
borhood of the heart and associated with regurgitant aortic-valve dis- 
ease. It may, however, be vibratile owing to peculiarities of form and 
of the condition of its walls and orifice. 

Aneurisms are often attended with a murmur. This generally cor- 
responds to the cardiac systole and therefore to the tidal wave of the 
pulse, and is of a blowing character. It is probably created as a rule 
in the artery, and due either to contraction of its tube at the point of 
origin of the aneurism or to some irregularity of that part ; but it is 
more or less modified, or it may be developed in some cases, by res- 
onance in the aneurismal cavity. Murmurs may equally be produced 
by the pressure of tumors or even of the stethoscope upon healthy ar- 
teries. Aneurisms of the aortic arch are, like other aneurisms, some- 
times attended with a murmur synchronous with the heart's systole, 
and like them may be free from murmur. But in this case a double 
murmur is not un frequent, especially if there be associated regurgitant 
aortic-valve disease. In these aneurisms, again, it is not uncommon to 
hear the two cardiac sounds, or two sounds resembling them, even more 
distinctly than over the heart itself. They have been supposed to origi- 
nate within the aneurism, but are doubtless the normal cardiac sounds 
carried by the blood-stream, and are probably increased by resonance. 

The pulse is often distinctly affected in aneurism. But the affection 
is not so much due to the aneurism itself (though this doubtless has 
some influence) as to the narrowing of the artery, either from pressure 
or disease, which is so often associated with aneurism. It is most ob- 
vious when the aneurism involves either the innominate artery, or the 
subclavian, or the descending aorta, or one of the iliacs. In such cases 
the pulse in the implicated limb, as compared with that in the healthy 
limbs, is diminished in volume and strength, and appears to be re- 
tarded. The systolic rise is slow in attaining its maximum, and the 
diastolic fall presents a corresponding character. 

The symptoms due to the direct influence of aneurisms on surround- 
ing organs vary in different cases ; but their general character may be 
gathered from the remarks which have been already made. 

Treatment. — The treatment of internal aneurisms is far from satis- 
factory in its results. The chief object at which to aim is the gradual 
coagulation of blood within the cavity, and its consequent obliteration. 
This event occasionally takes place spontaneously in the case of bed- 
ridden patients or of those who are prostrated by lingering diseases — 
under conditions, therefore, in which the action of the heart and the 
circulation generally are unusually feeble. These facts furnish a clue 
to the general treatment which should be adopted. The patient should 



520 



DISEASES OF THE VASCULAR SYSTEM. 



be kept at as perfect rest as it is possible to enforce. He should be 
exposed to no causes of mental excitement, and strictly debarred from 
all forms of muscular exertion, including that of straining at stool ; if 
possible, therefore, he should be confined to his bed. His diet should 
be light and nutritious, and not more abundant than is necessary to 
maintain him in a condition of fair, but not robust, health. It is im- 
portant, too, that the bowels should be kept moderately free, either by 
enemata or mild laxatives, and, at all events, should not be permitted 
to become constipated; and that all bodily ailments which arise to com- 
plicate the aneurism should be, if possible, obviated or cured. Various 
drugs have been recommended, with the object either of quieting the 
circulation or of promoting coagulation. Among those which have 
been employed with reputed success are acetate of lead, iodide of potas- 
sium, and digitalis. It may well be doubted, however, whether either 
of these can have any real influence for good, and whether digitalis 
indeed is not likely to be injurious. Reduction of the volume of the 
blood, and of strength, by repeated copious venesections was formerly 
largely advocated; and it is not improbable that, in some cases at any 
rate, occasional bleedings may be really beneficial. To relieve pain or 
uneasiness opium is invaluable, and as local applications, with the same 
object, ice, belladonna, and other sedatives. 

Thoracic Aneurisms. 

These principally occur in the different parts of the aortic arch, in 
the descending thoracic aorta, and in the roots of the large arteries 
arising from the arch. They spring most frequently from the ascend- 
ing arch, and more commonly from the convexity than from the con- 
cavity of the arch. They usually form pulsating tumors which may be ! 
recognized as such if they abut on the surface of the chest, especially if 
they be also large, but which frequently escape recognition in conse- 
quence of being small or deep-seated. But whether they be positively 
recognized or not, they generally sooner or later produce groups of 
more or less characteristic phenomena by compressing the various sur- 
rounding organs, and interfering with them in the due performance of 
their functions, and end fatally in one of several fully recognized modes. 
It is obvious that the situation of the tumor and the facility with which 
it may be recognized, the parts which are specially liable to compres- 
sion, and the nature of the event must be largely determined by the 
part of the aorta whence the aneurism springs. 

Morbid Anatomy. — Aneurisms of that portion of the aorta which is 
embraced by the pericardium are almost invariably of small size, and 
are therefore liable to be confounded with simple aortic valvular dis- 
ease, or degenerative arterial changes, with both of which they are 
commonly associated, or else altogether to escape recognition. They 
occasionally open into the pulmonary artery, right ventricle or auricle, 
or vena cava, sometimes lead to the production of loculated aneurismal 
cavities, extending into the substance of the cardiac walls or along the 
auriculo-ventricular grooves ; and are very apt to rupture at an early 
period into the pericardial cavity. 



THORACIC ANEURISMS. 



521 



Aneurisms of the rest of the ascending arch often attain a very 
large size. In their growth they encroach, as a rule, on the upper 
part of the right side of the thorax, displacing the lung outwards, 
and coming in contact by their anterior surface with the anterior 
thoracic parietes. They not unfrequently also displace the heart 
downwards and to the left. According to the amount of the displace- 
ment of the lung will be the extent of the dulness on percussion to 
which they give rise, and that of their visible pulsation. This may be 
heaving, vibratile, or purring, and if visible to the eye will probably 
be seen distinctly to alternate with that of the heart. As the tumor 
enlarges it causes bulging of the chest- wall superficial to it, and soon 
(eroding the ribs and their cartilages, the sternum perhaps and clavicle, 
and involving the muscular tissue) forms a more or less hemispherical 
pulsating mass. In the interior of the chest it presses upon the right 
lung, which often becomes adherent to it and expanded in some degree 
over it; and it is apt to compress either the vena cava desccndens or 
the left innominate vein, or both, impeding the passage of blood through 
them, or rendering them completely impermeable; and it may even 
involve the right pneumogastric nerve or the sympathetic trunk. 
Aneurisms in this situation are liable to open externally, or into the 
pericardium or right pleura, or into the lung itself and thence into one 
of the bronchial tubes, or even into the right bronchus. 

An aneurism of the transverse arch, if it spring from its front or 
convexity, tends chiefly to expand upwards and to the left, so that it 
presses upon and causes erosion of the manubrium of the sternum and 
of the adjoining portions of the left upper ribs and cartilages and 
clavicle, and forms a tumor which occupies the situation here specified, 
and tends to rise from behind the sternum into the root of the neck. 
If it spring from the concavity or from the posterior aspect of the arch 
it is often quite latent. If it grow mainly upwards and in front, form- 
ing a manifest pulsating tumor, it may (like aneurism of the ascending 
arch) attain a large size and eventually burst externally; but much 
more frequently, owing to the confined limits of this portion of the 
chest and the many important organs which are contained therein, it 
causes death at a comparatively early period from the effects of pres- 
sure on one or other of those organs. Aneurisms of the transverse arch 
are especially liable to compress the trachea or the left bronchus, and 
may also involve the oesophagus, and often prove fatal by opening into 
one or other of these tubes. They may also compress or destroy the 
left recurrent laryngeal nerve or the left sympathetic or pneumogastric 
trunk; or obstruct the left innominate vein. Further, they may rup- 
ture into the pericardium or into the left pleura or lung. 

Aneurisms of the descending arch or of the rest of the thoracic aorta 
are rarely to be detected until they have acquired considerable magni- 
tude. They become superficial by destruction of ribs and vertebrae in 
the dorsal region to the left of the spine, and there in some cases form 
pulsating tumors of enormous size. But before they cause manifest 
tumor they may sometimes be recognized by the presence of dulness, 
pulsation, and murmur, and the absence of respiration over a limited 
area. It may be added that an important hint as to their presence is 



522 



DISEASES OP THE VASCULAR SYSTEM. 



often furnished by the occurrence of more or less constant gnawing, or 
aching, or burning pain in the situation of certain of the vertebrae, and 
of shooting or aching pains or uneasy sensations in the course of some 
of the nerves of the brachial plexus or of some of the intercostal nerves, 
more particularly on the left side. Aneurisms developed in these por- 
tions of the aorta not only tend to cause destruction of the bodies of 
the vertebrae and of the posterior parts of the corresponding left ribs, 
and to involve the dorsal spinal nerves and the sympathetic trunk of 
the same side, but are also especially apt to compress the oesophagus 
and ultimately to open into it, or to rupture into the left pleura. They 
may indeed rupture into the right pleura. Those which form in the 
upper part of the chest may also compress the trachea, left bronchus, 
or left lung, and eventually open into one or other of them. 

Symptoms. — It may be convenient to pass in review the various 
pressure-symptoms to which aneurisms of the thoracic aorta give rise, 
and of which several are often present when as yet no tumor can be 
discovered by auscultation, percussion, palpation, or inspection. They 
are as follows : 

1. Impediment to the Arterial Circulation. — This may depend either 
directly on the aneurism or on the presence of atheromatous or other 
thickening of the vessels springing from the arch. Not unfrequently 
the artery of one arm is alone affected, and the radial pulse of that 
arm becomes comparatively feeble, or it may be entirely annulled. 
Sometimes both carotid and subclavian of one side are thus affected ; 
and occasionally all the arteries springing from the arch are impli- 
cated, so that all visible pulsation in them and in their branches ceases. 
When, however, the impediment to the circulation is so general, it has 
usually come on gradually, and there have been previous stages in 
which one or two arteries only have been involved. In consequence 
of impediment to the carotid circulation we not uncommonly find 
patients with aneurism of the arch liable to momentary attacks of 
vertigo, or loss of consciousness, sometimes attended with epileptiform 
convulsions. 

2. Impediment to the Venous Circulation. — When the vena cava or 
both innominate veins are obstructed, the veins at the root of the neck 
form spongy masses immediately above the clavicles, and those of the 
head and the neck and arms and upper part of the chest undergo great 
distension. The cutaneous surface becomes congested, especially that 
of the face, the eyeballs injected and prominent, and before long the • 
head, neck, and upper extremities swollen with oedema. The patient 
suffers also from drowsiness, coma, and other cerebral symptoms, and 
extreme dyspnoea. When the innominate vein only is obstructed, the j 
distension of veins and oedema are limited to one arm and one side of 
the head, neck, and chest only. In this latter case if the patient's life 
be prolonged it is not unusual for remarkable clubbing of the fingers 
of the affected limb to supervene. 

3. Pressure on Nerves— Pressure on the left recurrent laryngeal 
nerve is soon attended with paralysis of the intrinsic muscles of the 
larynx which it supplies. The left vocal cord remains immovable 
midway between the position of closure and that which it should | 



THORACIC ANEURISMS. 



523 



assume during ordinary calm respiration, and the patient's voice loses 
its musical character and becomes hoarse or whispering. Pressure on 
the right recurrent, which may be produced by innominate or sub- 
clavian aneurism, will have a corresponding effect on the right vocal 
cord. It has often been observed that in intrathoracic aneurism one 
of the pupils is either (as compared with its fellow) abnormally dilated 
or abnormally contracted. Abnormal dilatation has been attributed to 
pressure upon the sympathetic trunk in the upper part of the neck 
causing irritation ; abnormal contraction to pressure on the same trunk, 
but sufficient to destroy it or to annul its function. The pneumogastric 
nerve is at least as liable as the sympathetic to suffer, and to its com- 
pression, congestion and gangrene of the lungs have been attributed. 
The effects of pressure on the intercostal nerves and brachial plexus 
have already been considered. It is obvious that these phenomena of 
nervous interference must be looked for chiefly in aneurisms situated 
to the left of the mesial line. 

4. Pressure on Trachea and Bronchial Tubes. — The constantly in- 
creasing pressure of an aneurism on the trachea, if exerted laterally, 
displaces it to a greater or less extent; but under any circumstances 
the pressure sooner or later drives that portion of the surface against 
which it is exerted inwards, first flattening it, and then causing it to 
bulge so as to reduce the tracheal channel at this part to a mere semi- 
lunar chink. This process is attended with the gradual involvement 
of the tracheal Avails in those of the aneurism and their infiltration 
with inflammatory products, followed by their gradual disintegration 
and final perforation. While it is going on, the patient suffers first 
from more or less stridor of the respiratory sounds, which becomes 
especially audible if, from excitement, or exertion, or the act of cough- 
ing, the respiratory acts are hurried or deepened. The breath is at 
the same time short after exertion. Gradually these symptoms in- 
crease and cough is superadded. The cough is at first occasional and 
dry, but soon becomes more or less paroxysmal and each paroxysm is 
relieved by the discharge of a small quantity of mucus. The stridu- 
lus respiration, and the stridulous cough in prolonged paroxysms 
(threatening, and sometimes ending in suffocation) are peculiarly sug- 
gestive of the presence of an aneurism or other tumor in the thorax. 
The suffocative cough is due to the occasional closure by mucus of the 
narrow tracheal chink and the mechanical -difficulty which there then 
is in effecting its dislodgment. Hoarseness, or loss of the musical 
quality of the voice, exists only when, associated with the tracheal 
pressure, there is pressure on the recurrent laryngeal nerve, or some 
distinct affection of the vocal cords. Accumulation of mucus in the 
bronchial tubes, lobular pneumonia, congestion of lungs, and pneu- 
monia are all of them common sequelae of tracheal obstruction. When 
one only of the bronchi is obstructed, feebleness of respiratory murmur 
and imperfect expansion may be observed on the affected side of the 
chest, on which presently supervene rhonchus, crepitation, and other 
signs of one or other of the lung affections just enumerated. 

5. Pressure on the oesophagus causes the ordinary phenomena of oeso- 
phagal stricture. 



524 



DISEASES OF THE VASCULAR SYSTEM. 



Thoracic aneurisms are often exceedingly difficult, of diagnosis, partly 
because the symptoms to which they give rise are obscure, partly be- 
cause many affections simulate them in their general and local symp- 
toms. Among the more important of these affections are : first, per- 
sistent violent palpitation of the heart, such as is met with in Graves's 
disease ; second, hypertrophy and dilatation of the heart, associated 
with regurgitant aortic valve disease. In both of these conditions there 
is often violent pulsation, attended with purring tremor of the arch of 
the aorta and of the large vessels which spring from it ; and in both 
marked pulsation and the cardiac sounds may be propagated over a 
considerable portion of the right infraclavicular and mammary regions. 
There may even be, in the latter case especially, some retraction of the 
anterior edge of the right lung and consequent extension of cardiac dull- 
ness to the right. As further conditions liable to be mistaken for 
aneurism (especially if they be associated with palpitation or heart 
disease) are mediastinal tumors, consolidated portions of lung, and ab- 
scesses or growths involving the thoracic parietes. 

In the foregoing account we have mainly referred to the typical 
forms of aortic aneurisms. We may add that aneurisms of the intra- 
thoracic portions of the large arteries which spring from the arch, pre- 
sent much the same local and general symptoms as do aneurisms spring- 
ing from the aorta itself in their immediate neighborhood. They are 
to be distinguished mainly by their position and by the special influence 
which they exert on the circulation through the artery with which they 
are connected. We may further add, that so-called " disssecting aneu- 
risms" are not unfrequent in the aortic arch. They are produced by 
the sudden laceration of the diseased or merely thinned internal coat 
of the artery, and the effusion of blood through the rent into the inter- 
val between the external and internal coats, and generally into the sub- 
stance of the middle coat. The extent to which the dissection may 
take place, and the event both vary. In some cases the dissection is 
limited to a small well-defined area; in other cases it circumscribes the 
vessel and occupies an inch or two of its length ; and in other cases, 
again, it involves the whole length of the aorta. As regards result, 
dissecting aneurisms occasionally undergo spontaneous cure by the co- 
agulation of the extravasated blood ; sometimes they prove fatal by 
causing complete obstruction of the aorta, in the thorax or abdomen ; 
but more frequently they terminate in laceration of the external mem- 
brane, and the effusion of blood into some cavity, such as the pericar- 
dium, or into the connective tissue of the mediastinum or some other 
part. 

Treatment. — In addition to the general plan of treatment which has 
been laid down for aneurisms, it is sometimes possible, from the fact 
that aneurisms of the ascending and transverse arch and of the vessels 
which spring from them come speedily into relation with the anterior 
walls of the chest, to employ mechanical or other means to cause coagu- 
lation within them. The methods which have been had recourse to, 
but unfortunately with very imperfect success, are galvano-puncture, 
the injection of perchloride of iron or other styptics, and the insertion 
of coils of thin iron wire or of needles. Ligature of the subclavian 



ABDOMINAL ANEURISMS. 



525 



and carotid arteries, especially of those of the right side in aneurism 
of the ascending arch, has occasionally proved beneficial ; it is less 
useful, however, here than in the treatment of aneurisms of the roots 
of these vessels. 

Abdominal Aneurisms. 

Morbid Anatomy and Symjrtoms. — These may be developed in con- 
nection with any part of the abdominal aorta or of its branches within 
the abdomen. Those which chiefly concern the physician are con- 
nected with the aorta, the cseliac axis, the superior and inferior mes- 
enteries, the renal and the common iliacs. The sources of abdominal 
aneurisms must be determined by their anatomical relations. They 
may generally, while still of medium size, be recognized as distinct 
pulsatile tumors, attended with more or less thrill and often with a 
murmur. It is easy, however, to mistake, especially in thin persons, 
the pulsation of the abdominal aorta for that of an aneurism, and 
especially so to mistake a carcinomatous or other tumor situated upon 
the aorta. Indeed, it is often impossible to distinguish accurately be- 
tween an aneurism and such a solid mass, unless we can by grasping 
the tumor distinctly satisfy ourselves that it does not expand, or by 
displacing it from its contiguity with the aorta annul its pulsations. 
[Before deciding positively as to the true character of an abdominal 
tumor, the physician should cause the patient to assume a position upon 
his hands and knees, and should carefully auscultate his abdomen and 
his back along the left border of the vertebral column, using when the 
former region is examined a flexible stethoscope. In this position if 
the pulsation is transmitted from the aorta to a superimposed tumor, 
it will cease unless indeed the tumor is bound down by adhesions; and 
so will any murmur that may have been previously heard. The mur- 
mur and pulsation will persist if there be an aneurism or vascular 
tumor, but a thorough consideration of the history and symptoms of 
the case will usually enable the physician to distinguish between these 
conditions, although the diagnosis of abdominal aneurism is confessedly 
one of the most difficult he is called upon to make.] Abdominal aneu- 
risms generally tend to attain a large size, to cause erosion of the ver- 
tebrae or other bones with which they come in contact, and to press 
upon the stomach, duodenum, or other viscera, on veins, and on nerves. 
They then cause pain in the back, which is sometimes very agonizing, 
and which tends to shoot along the branches of the lumbar nerves ; 
sickness from pressure on the stomach or obstruction of the duodenum; 
compression and even obliteration of the inferior cava, or of one of the 
common iliac or renal veins, causing dilatation of the veins of the 
lower extremities with anasarca, or similar conditions in one lower 
limb only, or in one of the kidneys. Abdominal aneurisms occasion- 
ally burst into the peritoneal cavity, or into one of the hollow viscera, 
or even into the spinal canal ; more frequently they rupture primarily 
into the retro-peritoneal tissue, whence blood may be effused round the 
oesophageal opening of the stomach or the duodenum ; or into the sub- 
stance of the mesentery, mesocolon, or great omentum, and may thus 
before the supervention of death cause complete obstruction of the car- 



526 



DISEASES OF THE VASCULAR SYSTEM. 



diac orifice, or of the duodenum, or of some other part of the bowel, 
and sometimes the most intense and long-continued agony of pain. 

Treatment. — The most important of the special modes of treatment 
of abdominal aneurisms are : first, that of putting a ligature round the 
aorta ; and, second, that of regulated pressure upon the aorta. The 
latter method may be carried out by the temporary application (say for 
eight or ten hours), under the influence of chloroform, of a specially 
adapted tourniquet to the aorta, if possible on the proximal side of the 
aneurism. Pressure may, however, be applied, with almost equal effi- 
cacy, on the distal side. It must not be forgotten, however, that the 
application of sufficiently forcible pressure completely to obstruct the 
aorta is attended with great risk of serious injury to the abdominal vis- 
cera, and hence it will generally be best to delay its employment until 
the effects of perfect rest have been fully tested. 



(3.) DISEASES OF THE VEINS. 
PHLEBITIS. 

Causation and Morbid Anatomy. — Inflammation of a vein is generally 
due either to the formation of a clot within it, in which case the process 
commences at the inner surface and travels outwards, or to the involve- 
ment of the vein in inflammatory processes which are going on round 
about it, in which case the walls are invaded from without inwards. 
Phlebitis, indeed, is almost always secondary. An exception to this 
rule is furnished by inflammation of the uterine veins after parturition, 
and by the comparatively rare thickening of the inner coat of veins 
which corresponds to the much more frequent thickening of the inner 
coat of arteries issuing in atheromatous and calcareous degeneration. 
The presence of clots may be regarded as an essential accompaniment 
of all forms of phlebitis, with the exception of that chronic form last 
adverted to. 

Inflammation of veins is characterized by thickening of their walls, 
connected with more or less active proliferation of the protoplasmic 
elements of their several laminse. This latter process is generally 
especially active in the outer coat, which not unfrequently acquires con- | 
siderable thickness and blends with the surrounding similarly affected 
connective tissue. Scattered abscesses are apt to appear here and there 
in its course. The inner coat tends to become rough and even to give 
rise to granulations. The contained clot, whether it be formed pri- 
marily or secondarily, soon fills the channel of the vein and adheres more 
or less firmly to its inner surface. At the same time it tends to lengthen 
both above and below — above to the junction of the vein with the next 
branch or its communication with a trunk vein, below into the tribu- 
tary branches. The further changes which such clots undergo will be 
considered under the head of thrombosis. 

The symptoms of inflammation of a vein are, if the vein be within 



VARIX. 



527 



reach of direct observation, pain and tenderness in its course with more 
or less distinct cylindrical thickening and hardening, and sometimes 
superficial redness. Abscesses in the course of the vessel, communi- 
cating or not with its interior, are not unfrequent. There is necessarily 
more or less febrile disturbance. The remote effects of phlebitis are on 
the whole much more important than the local effects. They embrace, 
on the one hand, those which are due to venous obstruction — dilatation 
of the distal veins, and anasarca ; on the other, those which depend on 
the discharge of fragments of thrombus, or of inflammatory or other 
hurtful matters into the circulating blood. These will all be best con- 
sidered elsewhere. 



VARIX. (Dilatation of the Veins.) 

Causation. — Dilatation of veins is much more common than that of 
arteries, but its causes are a good deal more obscure. It occurs no 
doubt generally in obstructive disease of the right side of the heart, 
and, when a vein is obstructed, throughout the venous system which 
is tributary to it, as well as in those collateral veins which take on, or 
divide between them, the duties of the defaulting vessel. But in a very 
large number of cases veins become dilated and varicose independently 
of all obstruction, independently of overwork, and independently also 
of obvious degeneration or weakening of their walls. 

Morbid Anatomy. — When veins dilate they become at the same time 
elongated, and consequently more or less tortuous. The dilatation 
usually commences, and is ahvays most marked, immediately above the 
valves, and the affected veins assume, therefore, an irregularly monili- 
form aspect. The walls, for the most part, become considerably thick- 
ened, although presenting occasional attenuations, especially over the 
convexities of the dilated portions. The thickening is principally due 
to hypertrophy of the middle coat, the attenuation to its atrophy or dis- 
appearance. With the progress of dilatation the valves become in- 
efficient and often shrivel up ; calcareous plates not unfrequently form 
in the middle coat; the connective tissue around becomes thickened 
and indurated, and blended with the outer coat of the vein ; phlebolites 
are often developed in the pouch-like protrusions; and these latter oc- 
casionally become perforated either by the extension of ulceration from 
without or by laceration. 

Dilatation may occur either in veins of medium or large size, or in 
those which are ordinarily mere capillary tubes. The former occur- 
rence is exemplified by the ordinary varicose veins of the lower ex- 
tremities, and by those of varicocele ; the latter by the tuft-like groups 
so common in the lower limbs of pregnant women. Dilatation and 
varicose condition of veins rarely require treatment at the hands of the 
physician. For him they serve mainly as important aids to diagnosis. 
Varicose veins in the lower extremities, varicocele, and haemorrhoids, 
are surgical disorders. Dilated or varicose veins of internal organs no 



528 



DISEASES OF THE VASCULAR SYSTEM. 



doubt occur, and aid in the production of functional disturbance ; they 
may even rupture and cause death by haemorrhage. We have witnessed 
this accident in a case of varicose veins of the oesophagus. But their 
presence can rarely if ever be recognized during life. The importance 
of the dilatation of certain groups of superficial veins in enabling us 
to judge of the seat and character of internal diseases involving the 
obstruction of deep-seated veins is obvious. 



(4.) — ARTERIAL AND VENOUS OBSTRUCTION 

THROMBOSIS AND EMBOLISM. 

There are few morbid processes of greater interest and, at the same 
time, of greater practical importance to the physician than those which 
we are now about to consider. They are the frequent causes of many 
obscure complaints as well as of some of the most clearly characterized 
maladies ; they may involve any organ of the body, and present at 
least as many different groups of symptoms as there are organs; and 
they are intimately related to some of the gravest forms of disease 
which come under our notice, such, for example, as pyaemia and puer- 
peral fever. The term thrombosis has been conveniently applied to the 
coagulation of blood during life in the heart, arteries, or veins, and 
includes within its meaning nearly all those cases which were formerly 
regarded as cases of phlebitis. The term embolism has been introduced 
to designate those cases in which an artery or vein becomes plugged by 
the impaction in it of a clot or other solid mass conveyed to it from a 
distance by the blood-stream. The morbid phenomena and symptoms | 
which they induce are partly referable to local inflammation, but prin- j 
cipally to arterial or venous obstruction. 

Thrombosis. 

Causation. — The causes of thrombosis are mainly stagnation or slug- I 
gish movement of the blood, the contact of the circulating fluid with 
inflamed or otherwise diseased surfaces, and special conditions of the j 
blood which render it apt to coagulate. 

Morbid Anatomy. — In the heart, after death, the blood which was 
contained within its cavities at the moment of death is generally found 
coagulated, moulded to the form of the cavities, and continuous with 
cylindrical clots occupying the trunk veins, and often with similar 
clots extending into the trunk arteries. These clots are sometimes 
black-currant-jelly-like, sometimes partly decolorized; and it may be 
added that the portions prolonged into the arteries are usually more or 
less completely decolorized, while those seated in the veins are usually 
soft and black. But not unfrequently the clots contained in the heart's 
cavities, and more especially those contained in the ventricles, are al- 
most entirely fibrinous, more or less opaque and buff-colored, close in 



THROMBOSIS AND EMBOLISM. 



529 



texture, and even indistinctly laminated. These, for many reasons, 
have obviously been formed during life, probably during the agony ; 
but are the consequence of dying and not the cause of death ; and on 
the whole (except from the fact that their deposition helps, as it were, 
to confirm the fatal issue) have little clinical importance. Their pres- 
ence, however, throws light on the mode of development of the peculiar 
bodies next to be considered. It is not uncommon to find after death, 
in certain cases, that rounded buff-colored masses, varying perhaps 
from the size of a pea to that of a walnut, are situated either in the 
apical portions of the ventricles, or in the appendages of the auricles. 
These, which are sometimes termed softening clots, usually occur in 
groups, are moulded to the surface on which they lie, adhere to it, and 
are continuous with one another by processes which underlie the carnece 
columnw; so that, with careful dissection, they may generally be re- 
moved as a continuous whole. They are sometimes smooth, sometimes 
ribbed upon the surface, and sometimes variegated in color. On sec- 
tion they may present a uniform character and consistence; but are 
more frequently broken down in their interior into a thick reddish or 
yellow pus-like fluid, containing products of disintegration only — fat 
granules, degenerating red and white corpuscles, cholesterin, and some- 
times hfematoid crystals. The bodies, in fact, are clots which have 
formed in the heart's cavities sufficiently long before death to have 
undergone the degenerative changes which clots formed elsewhere also 
undergo. They may be found in any of the heart's cavities, in one 
alone, or in two or more at the same time ; but are much more com- 
mon in the left ventricle than elsewhere. The conditions under which 
they are found are various, but they are especially common in cases of 
advanced heart disease or renal disease in which the patient has lain 
for weeks with an extremely feeble circulation, and with the balance 
trembling between life and death. During this period the enfeebled 
heart probably fails to empty its cavities completely, the blood remains 
stagnant or nearly so in those portions of them which are most remote 
from the direct current, and coagulation takes place slowly; or more 
probably suddenly, on one of those occasions, which are so common in 
these cases, when the patient falls into a state of apparent death, from 
which he rallies. Other clots of old formation, which may be found 
in the heart, are laminated clots such as are met with in aneurisms. 
They may be present in actual aneurismal dilatations of the ventricles, 
and have been discovered almost entirely occluding the left auricle 
behind a closely constricted mitral orifice. 

In the systemic veins the coagulation of blood during life is common 
enough. When the venous circulation is simply enfeebled, as we find 
it in the later stages of heart disease, and towards the close of phthisis, 
carcinoma, and other chronic wasting diseases, venous thrombosis is of 
frequent occurrence. It occurs then more particularly in the trunk 
veins of the lower extremities, and in those of the pelvis or at its brim. 
So again, when some impediment exists to the passage of blood along 
a vein, the distal portion of the vessel and in a greater or less degree 
the tributary branches become filled with clot. When veins are in- 
volved in inflammation which is taking place around them, the inflam- 

34 



530 



DISEASES OF THE VASCULAR SYSTEM. 



matory process, as has been pointed out, tends soon to pervade the 
entire thickness of the walls, and then to induce coagulation of the 
blood within them and their complete obstruction ; and occasionally, 
indeed, by perforation of the vein or in some other way pus or other 
inflammatory products find their way into the interior of the vein or 
into the substance of the thrombus. Thrombosis, secondary to inflam- 
mation, is common in erysipelas, diffuse cellular inflammation, car- 
buncle, and the like; in puerperal pelvic cellulitis; in inflammation 
involving the cancellous structure of bones, or the walls of the par- 
turient uterus; and in the venous sinuses of the interior of the skull 
in connection with disease of the internal ear. 

The different characters which venous thrombi display depend 
largely upon their age, and correspond to a considerable degree with 
those presented by cardiac clots. When fresh either they have a uni- 
form consistence and color, or there may be a central black cylinder, 
inclosed in a more or less complete fibrinous capsule. They do not at 
once necessarily fill the vessels in which they are seated, even if they 
be in a greater or less degree adherent to them, and hence fresh blood 
tends to insinuate itself between them and the venous parietes, and 
presently to coagulate there. The clots which finally occlude vessels 
thus become more or less distinctly laminated. In their further prog- 
ress venous thrombi undergo various changes. In some cases they 
blend with the venous walls, and, becoming converted into connective 
tissue, cause the obliteration of the vessels ; in other cases they undergo 
softening in their interior and conversion into loculated cavities full of 
fatty detritus and caseous remnants of white corpuscles ; in other cases 
they undergo actual suppu ration or conversion into abscesses. 

Arterial thrombosis is due in a large number of cases to simple stag- 
nation of blood. Thus the arteries leading to a district, in which 
(owing to the morbid processes going on in it) the blood has ceased to 
circulate, become secondarily filled with coagulum. And in precisely 
the same way, if an artery be ligatured, or obliterated at any point by 
the pressure of a tumor or of a tourniquet, the proximal portion of the 
vessel up to the nearest branch becomes the seat of thrombosis. Not 
unfrequently also, when the circulation is simply feeble, obliteration of 
an artery by coagulation of its contents takes place. This occurrence 
in the smaller branches of the pulmonary artery is a common cause of 
pulmonary apoplexy. It is met with occasionally also in the arteries 
of the extremities and even in the aorta itself. Diseases of the inner 
coat of . arteries — atheroma, calcification, arteritis, and syphilis — are all 
of them liable to induce thrombosis and consequent obliteration. 
Among the arteries which are especially liable to suffer thus are those 
of the base of the brain and those of the extremities. The varieties of 
arterial clots and the changes which take place in them are identical 
with those which have been described in connection with veins. 

Embolism. 

Causation and Morbid Anatomy. — The sources of emboli are mainly 
venous thrombi, cardiac vegetations, and disintegrating calcareous, 



THROMBOSIS AND EMBOLISM. 



531 



atheromatous, or inflamed surfaces. Additional sources are softening 
clots in the interior of the heart, and morbid growths or other adven- 
titious bodies. 

The detached solid mass, whatever its nature, is carried along more 
or less rapidly by the blood-stream until it reaches a vessel which is 
too small to allow of its further progress. The point at which it becomes 
arrested usually corresponds to the bifurcation of a vessel or to the 
giving off of a comparatively large branch. Here it becomes wedged, 
sometimes blocking up the channel completely, but more frequently 
forming at first a partial impediment only. In the latter case the con- 
stant pressure from behind tends to drive it farther and farther onwards, 
in consequence of which, or of the gradual coagulation of blood around 
it, the vessel becomes at length, as in the first case, completely occluded. 
Subsequently thrombosis takes place on both sides of the embolus, the 
artery and its distal branches become filled with clot, which, gradually 
undergoing changes, blends on the one hand with the arterial parietes, 
and on the other with the embolus. So that although the embolus 
may, at first, be readily recognized as an independent body, it often 
becomes undistinguishable from the thrombus to which its presence 
has given rise. 

Emboli taking their origin in the systemic venous system, or in the 
right side of the heart, necessarily become fixed in the pulmonary arte- 
ries. Those which originate in the pulmonary veins, in the left side 
of the heart, or in the larger systemic arteries, are conveyed to the 
periphery of the systemic arterial circulation. And those, lastly, which 
are yielded by the veins of the chylo-poietic viscera find their resting- 
place in the branches of the vena portce. 

Owing to the infrequency of disease of the valves of the right side 
of the heart, embolism involving the lungs is almost invariably due to 
the detachment of venous thrombi or fragments of them. In some 
cases entire systems of thrombi become free, and a complete cast, some 
inches long, of a venous tree may be carried into the pulmonary artery 
and impacted in a more or less convoluted form within it. More fre- 
quently shorter lengths become successively separated and successively 
lodged in different branches of that vessel. It is much more common, 
however, for the venous clots to crumble, as it were, gradually away ; 
and for minute fragments to become impacted from time to time in the 
pulmonic arterioles. 

It is rare for thrombosis to take place in the pulmonary veins ; and 
hence embolism is seldom due to this cause. The most common cause 
of embolism of the systemic arteries is undoubtedly the detachment of 
granulations from the diseased aortic or mitral valve ; but another fre- 
quent cause is the separation of atheromatous or calcareous particles, 
or other detritus, either from the valves or inner surface of the heart or 
from the large arteries. It is obvious, therefore, that embolism of the 
systemic arteries must be in a very large proportion of cases dependent 
on valvular disease, and must be regarded as one of the common risks 
of that affection. Emboli from the various sources just indicated are 
carried along the aorta and thence into some of the smaller branches of 
the systemic arteries — whither is in some degree a matter of accident. 



532 



DISEASES OF THE VASCULAR SYSTEM. 



There are certain organs, however, which are specially prone to suffer ; 
but it is probable that their arteries are not so much specially liable to 
obstruction, as that their obstruction produces particularly serious and 
obvious ill-effects. The organs here referred to are the brain, liver, j 
spleen, and kidneys ; and, it may be added, the lower extremities. The 
cerebral arteries chiefly liable to obstruction are the middle cerebral 
branches of the internal carotids; and it is curious that the obstruction 
generally occurs in the middle cerebral of the left side. 

Consequences and Symptoms of Thrombosis and Embolism. 

It is certain that, whenever a thrombus forms or an embolus becomes 
fixed, inflammation of the implicated vascular walls, if it did not pre- 
viously exist, speedily ensues and that hence pain and tenderness will 
mark the course of the vessel if it be within reach of investigation, and 
more or less febrile disturbance tends generally to be present. It is 
further certain that in both cases complete obstruction to the passage of 
blood through the affected vessel takes place very speedily if not quite 
suddenly. It is this fact, indeed, which gives to thrombosis and em- 
bolism in common their characteristic features, and which renders it 
difficult, if not impossible, to make any practical distinction between 
them. In aid of correctness of diagnosis it may, however, be pointed 
out : first, that obstruction of the pulmonary and systemic veins by 
clots can be due to thrombosis only ;' second, that obstruction of arteries- 
or of the portal veins may be due either to thrombosis or embolism ; 
third, that the pre-existence of systemic venous thrombosis renders it 
probable that any obstruction occurring in the pulmonary arteries is 
due to embolism; and, lastly, that the presence of valvular disease on 
the left side of the heart, or the fact of previous rheumatism always 
renders it probable that supervening obstructive disease of any of the 
smaller systemic arteries is of embolic origin. 

The results of venous thrombosis are stagnation of the blood in the 
tributary veins with dilatation, followed soon by compensatory dilata- 
tion of the anastomotic veins, and by oedema. These conditions are 
not secondary to thrombosis only, but attend all cases in which veins 
from whatever cause are obstructed. The consequences of arterial 
thrombosis or of embolism, on the other hand, are impairment of 
nutrition of the region which the artery supplies, which may be fol- 
lowed by congestion, haemorrhage, inflammation, degeneration, or gan- 
grene, together with special symptoms due to the organ or part whose 
integrity is compromised. Similar symptoms, it may be added, follow 
upon all forms of arterial obstruction, no matter how they are produced. 
The special effects of thrombosis and embolism will for the most part 
be best discussed in association with the other morbid conditions of the 
several organs in which they occur. There are two or three cases, 
however, which may be most conveniently considered now. They are 
phlegmasia alba dolens, thrombosis and embolism of the heart and of 
the branches of the pulmonary artery, obstruction of the larger arteries 
of the limbs, and multiple thrombosis or embolism of the smaller sys- 
temic arteries. 



THROMBOSIS AND EMBOLISM. 



533 



Particular Cases of Thrombosis and Embolism. 

1. Phlegmasia alba dol-ens. — This term is generally applied to the 
painful and (edematous condition of leg which often follows upon par- 
turition. A condition, however, almost exactly similar may occur 
independently of parturition, and even in males, and not unfrequently 
becomes developed in the course of phthisis and carcinoma. The 
arms also may be affected in like manner as the lower extremities. 
Phlegmasia alba dolens is due to thrombosis of the trunk veins of the 
limb, or of the. larger veins to which these converge, which become 
converted into painful rigid cords. When this affection follows par- 
turition it generally commences from a week to a month after that 
event, and almost invariably in the left lower limb. And even if the 
right become affected it is usually affected in association with the left 
and at a later period. The commencement of this disease is generally 
sudden and indicated by the concurrence of diffused pain throughout 
the affected member, and oedema. The pain varies in character and in 
intensity, and is generally attended with soreness or tenderness, some- 
times Avith distinct hyperesthesia, sometimes with loss of sensation; 
and not unfrequently the patient is unable, either from pain or loss of 
power, to move the limb or any of its parts. The oedema gradually 
increases until the limb becomes large and smooth, and of a peculiar 
pale waxy aspect; it does not generally pit distinctly on pressure, and 
often presents remarkable elasticity and tension. The superficial veins 
generally become dilated and unusually visible; and the skin, more- 
over, often presents a mottled, ret i form character, owing to the rup- 
ture, as in pregnancy, of the deeper layers of the cutis. There is not 
as a rule any manifest change of temperature in the affected limb; but 
more or less general febrile disturbance is usually present. If there be 
no serious complication, the patient probably recovers at the end of 
three or four weeks. For the most part, however, the veins primarily 
obstructed remain impervious ; and sometimes there may be more or 
less permanence of oedema. 

Treatment. — Little can be done in the way of special treatment for 
phlegmasia dolens or other oedematous conditions arising from ob- 
structed veins. It is generally desirable that the patient should be kept 
at rest, and the affected limb elevated or in the horizontal position. If 
there be distinct inflammatory mischief in the course of a large vein, a 
few leeches may be serviceable; and when oedema, with tenderness, is 
present, it is generally of benefit to envelop the limb in wadding or in 
flannel, in order to keep it warm and promote perspiration. Hot fo- 
mentations and baths may also be employed. The internal treatment 
must be determined by the general condition of the patient; but for the 
most part tonics are chiefly indicated. 

2. Cardiac Thrombosis. — It is not easy to specify symptoms by which 
clots formed in the heart during life may be recognized. It is possible 
of course that they may occasionally, from their position, interfere with 
the due action of the valves, and so induce endocardial murmurs; but 
it is certain that in the great majority of cases they have no such effect. 



534 



DISEASES OF THE VASCULAR SYSTEM. 



It may be taken for granted that their presence must in almost all cases 
be a source of embarrassment to the heart's action, and that they must 
therefore tend to aggravate the feebleness of circulation out of which 
they arose, and to increase the severity of the cardiac symptoms which 
the" patient had previously suffered from. It is important, however, to 
know that in those cases in which such clots form in the heart, the fee- 
bleness of circulation which determines their presence there very com- 
monly indeed determines their formation in arteries and veins also; and 
that hence the condition of the lungs and kidneys, of the connective 
tissue, and of the skin, may be of some assistance in the formation of a 
diagnosis. The detachment of such a clot and its entanglement in one 
of the valvular orifices of the heart have been assigned as a cause of 
sudden death. 

3. Embolism and Thrombosis of the Pulmonary Artery. — We do not 
here intend to discuss the results of that blocking up of the smaller 
branches of the artery which is so commonly associated with,' and so 
often the cause of pulmonary apoplexy, lobular pneumonia, circum- 
scribed abscesses, patches of gangrene, and the like. Our object is to 
consider those embolic or thrombotic obstructions of the arterial trunk, 
or of its chief divisions, which are occasionally the cause of sudden 
death. 

It is now well established that the chief danger of thrombosis of the 
larger systemic veins is that of the separation of the whole or of a large 
portion of the clot and its impaction in the trunk of the pulmonary 
artery. This accident is especially apt to occur in cases of phlegmasia 
dolens, and in cases in which, after parturition, the uterine veins have 
become similarly plugged. The patient, probably in the midst of ap- 
parently fair health, is suddenly seized with severe pain in the region 
of the heart, attended with intense distress and gasping for breath, pal- 
lor or lividity of face, extreme feebleness or even suppression of pulse, 
and dies collapsed. It has been disputed whether death is due to as- 
phyxia or to syncope. It is certain, however, that the sudden obstruc- 
tion of the pulmonary artery causes " shock," or collapse, and that the 
patient sometimes dies of this shock within a few seconds ; and it is 
further certain that the symptoms of sudden obstruction are often undis- 
tinguishable from those of angina, or of rupture of an aneurism, or of 
the heart itself, into the pericardial cavity. Indeed, the symptoms of 
pulmonic obstruction are by no means typical ; and its diagnosis must 
mainly depend on the association of the symptoms above described with 
those conditions of the venous circulation which are known to be pro- 
ductive of embolism. 

There are, however, two or three points in relation to this subject 
which demand a word or two of comment. First : sudden obstruction 
of the pulmonary artery by an embolus, even if it be attended with 
symptoms of great severity, does not necessarily end in immediate death. 
The clot may be driven onwards into a branch, the symptoms of im- 
pending death subside, and the phenomena due to the obstruction of 
a branch only presently ensue. Second: it is important to bear in 
mind that many of the recorded cases of sudden death from pulmonary 
embolism are cases in which the only foundations for this diagnosis 



THROMBOSIS AND EMBOLISM. 



535 



! were suddenness of death (possibly from syncope), and the discovery 
after death of an ordinary fibrinous clot in the right ventricle, prolonged 
I from thence into the pulmonary artery and its branches — a clot origi- 
nating in the spot in which it was found, and the consequence of dying, 
I not the cause of death. Third : thrombi occasionally form in the larger 
I branches of the pulmonary artery. Occasionally, indeed, the trunk and 
j the greater number of its branches are almost entirely occluded by such 
clots. It is a fact that these may form without pain, and cause little 
or no distress, until by some little displacement of them, or by the sud- 
den coagulation of the blood still passing between them and the walls 
of the tubes in which they lie, they suddenly bring the pulmonary cir- 
culation, and with this life itself, to a stop. 

4. Embolism and Thrombosis of the larger Systemic Arteries. — It some- 
times happens that either from embolism or from thrombosis, one or 
more of the arteries of the legs, or the femorals, or the iliacs, or even 
the abdominal aorta itself, become obstructed. And the same thing 
may occur in respect of the arteries of the upper extremities. The 
immediate result is serious impediment to the circulation of the impli- 
cated limb or limbs, characterized by cessation, or at all events dimi- 
nution, of the pulsation in the vessels beyond, and more or less pallor 
and coldness. In some cases collateral arteries gradually enlarge, and 
the general condition of the limb after a time becomes normal. In 
other cases the circulation comes generally, or in certain area?, to a 
permanent standstill, the affected parts gradually lose their tempera- 
ture, the surface becomes pallid, but mottled with purplish spots, and 
the tissues assume a doughy consistence. Bulla?, filled with sanious 
fluid, soon rise upon the discolored patches, and gangrene becomes 
established. Arterial embolism is generally attended with severe pain 
at the point of impaction, and much pain and tenderness are generally 
present in the course of plugged arteries. It usually happens, more- 
over, that pain and tenderness are, for a time at least, present in a 
greater or less degree in the parts which are in process of sphacelation. 

Treatment. — For the local treatment of gangrene little can be done 
beyond keeping the parts warm. For this purpose they may be greased 
and covered with cotton-wool or wadding. For general treatment, it 
is chiefly important to maintain the patient's strength by the adminis- 
tration of food and stimulants, aided by tonics ; and to relieve pain 
and distress by the use of opium. 

5. Of multiple thrombosis or embolism of the smaller systemic arteries, 
a not uncommon result of some forms of heart disease, all that need be 
said is that the symptoms, which are generally somewhat vague, and 
the appearances found after death, often present a considerable resem- 
blance to those of pysemia. 



536 



DISEASES OF THE VASCULAR SYSTEM. 



(5.)— DISEASES OF THE DUCTLESS GLANDS AND BLOOD. 

DISEASES OF THE THYROID BODY. 

To diseases of this organ the name of goitre or bronchocele is com- 
monly applied. It is more convenient, however, to restrict these names 
to a certain group of hypertrophic affections than to include under them 
every variety of lesion to which the thyroid body is liable. 

The chief affections which would on these grounds be excluded are 
inflammation and carcinoma. 

Idiopathic inflammation of the thyroid body is certainly of unfrequent 
occurrence ; it may, however, follow secondarily upon goitre, or result 
from operation, or from injury inflicted upon the gland. It is probable 
also that some of the overgrowth of the hypertrophic organ may be due 
to chronic inflammation. 

Carcinoma of the thyroid body is extremely rare. Undoubted ex- 
amples of this affection have however been recorded, in some of which 
the morbid growths were primary, in others due to extension from 
neighboring organs, in others secondarv in the usual sense of that term. 

It is needless to discuss particularly the symptoms to which these 
conditions give rise, or the special treatment which they may require. 

Goitre. [Bronchocele.) Cretinism. 

1. Goitre. Causation. — The circumstances under which goitre arises 
are very various and not very clearly understood. There is no doubt 
that it is altogether far more common in females than in males ; and 
indeed, as regards women, it has long been known that there is not 
unfrequently a tendency to some temporary enlargement of the thyroid 
body both during pregnancy and at the catamenial period. It is occa- 
sionally observed in the foetus, and is then commonly associated with 
some peculiarity in the form and situation of the gland. 

Goitre appears to originate with special frequency between the ages 
of eight and puberty ; but rarely, if ever, after forty. It occurs in a 
sporadic form in probably all parts of the globe ; that is, isolated cases, 
for which no cause can be assigned, are nearly everywhere occasionally 
met with. It is remarkable, on the other hand, that goitre occurs 
endemically in many limited districts scattered nearly all over the 
world. Such places are in England met with in Derbyshire, Hamp- 
shire, Nottinghamshire, Sussex, and Yorkshire. Goitrous districts are 
for the most part of peculiar geological formation ; they are mostly 
valleys, and usually their soil or that of the adjoining mountain ranges 
is largely formed of lime or magnesian limestone, and the water of the 
wells or of the watercourses which traverse them is largely impregnated 
with carbonate or sulphate of lime, with which magnesia is in a con- 
siderable number of cases associated. Various reasons have been 
assigned for the prevalence of goitre in these localities. All evidence, 
however, seems now to point to the drinking water as the efficient 



GOITRE AND CRETINISM. 



537 



agent in the production of the disease ; and it is generally held that 
the poisonous ingredient is either the sulphate or carbonate of lime, or 
both, in association probably with magnesia. The main objection to 
this view — and it is a serious one — is, that hard waters containing such 
ingredients in excess occur and are used in non-goitrous localities by 
persons who never become goitrous. And hence it is probable, as is 
suggested by Virchow, that these salts do not act directly, but that 
there is associated with them some other principle of a malarious char- 
acter to which the goitrous tendency is essentially due. It may be 
added that endemic goitre is endemic in the strict sense of the term ; 
that it belongs, as it were, to the locality; that new-comers are liable 
to suffer equally with those who have been born and bred in it (allow- 
ance being of course made for the relative length of their exposure to 
\the goitrous influence); and that, although the children of goitrous 
parents become in large proportion goitrous in such localities, the 
goitrous tendency is not hereditary, and ceases in them when they are 
removed from the influence of the poisonous principal. In goitrous 
districts goitre is not limited to man ; but dogs, mules, and horses, are 
all liable to suffer. 

Morbid Anatomy. — Goitre consists in a kind of hypertrophy of the 
normal constituents of the gland, namely, the bloodvessels, the connec- 
tive tissue, and the groups of intercommunicating vesicles forming the 
ultimate lobules which the connective tissue circumscribes. In some 
cases all of these become increased in equal proportion, and the goitre 
then differs little if at all, except in bulk, from the healthy organ. 
More frequently, however, one of these constituents undergoes dispro- 
portionate development, and hence the texture of the tumor becomes 
characteristically modified. Thus, sometimes the connective tissue 
alone undergoes hypertrophy, and the tumor grows hard and dense; 
sometimes the vascular tissue especially becomes preternaturally de- 
veloped, the veins and arteries, or more frequently the veins alone, 
attaining comparatively enormous dimensions, sometimes the vesicles 
are the chief seat of change — they become dilated and filled with an 
albuminous fluid, or a solid albuminoid or gelatinous substance. Such 
cysts, partly by simple dilatation, partly by coalescence, may attain the 
size of a pigeon's or hen's egg, or even a larger bulk. In a case 
recorded by Mr. Spencer Watson, a cyst of this kind yielded on punc- 
ture a pint and a half of blood-colored fluid. It must be added that 
cysts of considerable size may be developed in glands which in all other 
respects are healthy; that a goitrous tumor may become, in whole or in 
part, the seat of inflammation, and that consequently blood may be 
poured out into the cysts which it contains, or suppuration and ulcera- 
tion may take place in it; and that degenerative changes may ensue 
after a time, the cells within the cysts undergoing fatty disintegration, 
and the contents of the cysts consequently acquiring a milky character, 
or the fibroid stroma becoming the seat of earthy deposition — a change 
which is often attended with diminution in size and induration of the 
tumor. 

A bronchocele varies in consistence according to the nature of the 
processes which have been going on in it ; so that in some cases it is 



538 



DISEASES OF THE VASCULAR SYSTEM. 



hard and resisting, in others it is soft and yielding or elastic, and in 
others, again, presents in certain situations distinct fluctuation; and 
when the enlargement of its arteries constitutes a special feature in the 
tumor, there may be pulsation resembling that of an aneurism. 

A goitre sometimes accurately retains the form of the healthy gland; 
but more frequently it becomes unsymmetrical in the progress of its 
growth (the right lobe being especially liable to disproportionate de- 
velopment), and then, by growing in certain- directions, or by throwing 
out lobules, may come to press inconveniently or dangerously on im- 
portant organs in its vicinity. Occasionally, indeed, small supplemental 
thyroid bodies may be detected in the neighborhood of organs thus 
hypertrophied; and it is especially by the development of such masses 
at the posterior part of the lateral lobes that compression of the 
oesophagus is sometimes effected. 

The size of a goitrous tumor varies from that which produces a mere 
fulness (by some persons regarded as ornamental) in the lower part of 
the front of the neck, to masses (usually then more or less irregular in 
form) which, roughly speaking, are as large as a cocoanut, or which in 
rare cases are of such enormous dimensions that they hang pendulous, 
from the neck, concealing the chest, the abdomen, and even extending 
to the middle of the thigh. 

Symptoms and Progress. — A goitre may generally be readily recog- 
nized by its relations with the various structures occupying the lower 
and anterior part of the neck, and especially by its situation in front 
of the trachea, and by the fact of its following the various movements 
of that tube. Its development is rarely attended with pain, and not 
usually with uneasiness; nevertheless various injurious consequences 
are apt to ensue. In the first place the tumor may prove seriously in- 
convenient by its mere bulk and weight. In the second place, it may 
exert pressure on the large veins in its neighborhood, or on the trunk 
of the sympathetic nerve, or on the pneumogastric or recurrent laryn- 
geal, or on the brachial plexus. And in the third place it may dis- 
place and compress the oesophagus or the trachea. Pressure on the 
oesphagus is mainly induced by enlargement of the posterior parts of 
the lateral lobes, or of the supplemental bodies occasionally found in 
this situation. Pressure on the trachea is by far the most important 
of the consequences which goitre entails.* In some instances it acts 
unilaterally, the trachea being displaced towards one side of the neck; 
in some instances this tube is compressed between the two enlarged 
lateral lobes; in some the pressure is exerted in the antero-posterior 
direction, the trachea then becoming more or less flattened against the 
spine. The effect of pressure in either of these cases is often quite 
remarkable, the implicated tracheal rings being not merely flattened, 
but actually made to form a convex bulging into the canal of the 
trachea, so that the passage is rendered on section semilunar or concavo- 
convex, or (if pressure be exerted equally on opposite sides) a rectilinear 
or biconcave chink, and it may be actually obliterated. A slight 
amount of compression is not unfrequent, the patient breathing natur- 
ally when quiet, but with some degree of noise and stridor and diffi- 
culty under exertion or excitement, and yet not with sufficiently pro- 



GOITRE AND CRETINISM. 



539 



nou need difficulty to excite alarm in himself or others. In all such 
cases, however, there is danger of the supervention of fatal obstruction. 
In some this takes place gradually from the gradual encroachment of 
the tumor; but in many it comes on more or less suddenly either from 
the rapid development of some cyst, or from inflammatory tumefaction, 
or from congestion and oedema of the mucous membrane of the already 
compressed trachea. It is important to bear in mind that the clanger 
of suffocation depends less on the size of the goitre than on its form and 
situation ; the most serious cases, indeed, are, first, those of substernal 
goitre, in which the lower portion of the gland, or some process of it, 
sinks, in the course of its enlargement, behind the sternum, and com- 
presses the trachea there, while there is yet little obvious sign of thyroid 
gland enlargement; and second, those of submaxillary goitre (a congenital 
defect described by Virchow) in which the gland is situated at a higher 
level than natural, and the lateral lobes extend backwards behind the 
angles of the jaws, and sometimes as far as the mastoid processes. The 
contraction of the sterno-thyroid muscles may materially aggravate 
the compression of deep-seated organs. To the list of clangers just 
enumerated may be added that due to the rupture of cysts or abscesses 
either externally or into the trachea or oesophagus. 

2. Cretinism. — Cretins are persons in whom feebleness of intellect 
or idiocy is combined with certain peculiarities of bodily conformation. 
They are for the most part stunted in growth, with tumid bellies and 
coarse skins. In a large proportion of cases they are more or less 
obviously goitrous, though occasionally the goitre is of the latent or 
submaxillary kind, to which reference has already been made. The 
head is usually large and misshapen, expanded at the sides and flat- 
tened at the top; the cheek-bones are high and prominent; the nose 
flattened or sunken at the bridge, broad at the root, and upturned ; the 
interval between the eyes increased ; the lips thick ; the mouth wide 
and usually open ; and the tongue large. There is generally more or 
less muscular weakness, deficiency of cutaneous sensibility, and impair- 
ment or annulment of the sexual functions ; and not unfrequently deaf- 
mutism is conjoined with the other corporeal defects. The degree of 
mental impairment varies between complete dementia and mere dulness 
or slowness of intelligence. Cretins are usually quiet and harmless, 
not given to mischief, but lia*ble to occasional outbursts of ungovernable 
violence. 

True cretinism appears, according to Virchow's researches, to origi- 
nate during foetal life in an unnatural tendency which the basilar por- 
tion of the occipital bone, the post-sphenoidal, and the prse-sphenoidal 
bones have to coalesce with one another by ossification of the disks of 
cartilage by which they should be at that time separated. The conse- 
quences are, that the base of the skull prematurely ceases to elongate, 
and thus becomes modified in form ; and that this arrest of develop- 
ment leads, on the one hand, to defective development of the corre- 
sponding portion of the brain, and, on the other, to wide-spread changes 
in the osseous framework of the skull and face. The form of the skull 
is modified partly by the need which its contraction in one direction 
involves of compensatory expansion on the part of those regions whose 



540 



DISEASES OF THE VASCULAR SYSTEM. 



bones have not yet coalesced, and partly by the opposing tendency 
which also exists in these cases to precocious union of the bones of the 
cranial vault along the lines of suture. The peculiar form which the 
face assumes is due in some measure to imperfect development of the 
nasal septum, in some measure to displacement of the cheek-bones and 
bones of the orbits. Further, in many of these cases the cranial bones 
acquire remarkable thickness, and the foramina at the base of the skull 
become much diminished in size. The same tendency which is pre- 
sented by the cranial bones is presented by those of the extremities, 
which soon become united with their epiphyses. And, indeed, it is 
probably due, in part at least, to this cause that these bones remain 
incompletely developed. 

According to the above account of the pathology of cretinism, this 
condition must be regarded as of congenital origin. Children are born 
cretins ; that is, they are born either with the peculiar features of cre- 
tinism more or less obviously developed, or they are born with that 
coalescence of the bones at the base of the skull which necessitates the 
gradual development of cretinism during the period of childhood. 

Like goitre, cretinism may occur either sporadically or endemically. 
The causes of sporadic cretinism and those of sporadic goitre are alike 
obscure. Endemic cretinism, however, and endemic goitre are always 
associated, and obviously originate in a common cause. Wherever 
goitre largely prevails there cretinism is also prevalent; the goitrous 
tendency, however, spreads over a wide area, and goitrous persons 
always largely outnumber their idiotic compatriots. It would seem, 
indeed, that for the production of cretinism some special intensity of 
the poison which also causes goitre is requisite. Cretins are not only 
in large proportion goitrous, but are also in large proportion the off- 
spring of goitrous parents. Yet there is no sufficient reason to believe 
that cretinism, any more than goitre or ague, is hereditary. For 
goitrous parents do not beget cretinous children when once they have 
removed from those regions in which these affections prevail, and under 
similar circumstances the children of cretins are themselves free both 
from goitre and taint of cretinism. It seems, indeed, clear that the 
morbific matter which, taken into the mother's system, causes in her 
goitre, acts also on her foetus, causing in it not only, it may be, goitre, 
but those special developmental changes which ultimately lead to mal- 
formation and mental deficiency. In reference to the association in 
cretinous infants of the arrested development of the base of the skull 
and goitre, it is interesting to bear in mind the fact, pointed out by 
Virchow, of the close proximity in the foetus of the base of the skull to 
the thyroid body. Assuming the common cause of goitre and cretin- 
ism to be, or to have some close relation with, the existence of a super- 
abundance of earthy salts in drinking water, it is natural to speculate 
on the influence which these salts may have in causing the too early 
completion of the process of ossification. 

We have referred to the great obscurity wmich involves the causa- 
tion of both sporadic goitre and sporadic cretinism. There is no evi- 
dence that the subjects of sporadic goitre ever beget either goitrous or 
cretinous children, or that sporadic cretins are ever the offspring of 



GOITRE AND CRETINISM. 



541 



goitrous or imbecile parents. At the same time sporadic cretins seem 
glways to present some abnormal condition of the thyroid body. In 
some recorded cases such cretins have been distinctly goitrous ; but in 
a large proportion of them there is an apparent absence of the thyroid 
body. In Dr. FaggeV cases, and in two previously recorded by Mr. 
Curling, there were soft elastic lumps occupying the angles between 
the sterno-mastoids and clavicles, which lumps, in Mr. Curling's cases, 
were found post mortem to consist of fat only. It may, however, be 
questioned whether these are not to be regarded as examples of that 
latent form of bronchocele which Virchow speaks of, and to which 
attention has been already directed. These facts evidently allay the 
cases of sporadic cretinism with those of the endemic form of the 
malady, and suggest the dependence of both on a common cause, the 
poison (if it be a poison) being introduced in the one case constantly 
and indifferently into the systems of a more or less extensive popula- 
tion, in the other case accidentally, so to speak, into the blood of casual 
units. 

Treatment. — In the treatment of goitre we have to consider first the 
medicinal and other means by which the tumor may be either reduced 
in size or prevented from increasing; and, second, the measures which 
may be requisite to obviate the effects of its pressure upon important 
parts. Whenever a goitrous patient lives in a goitrous district the ob- 
vious remedy is his removal thence into some more salubrious locality ; 
or, if this be impossible, a careful investigation of the available drink- 
ing water of the neighborhood, and the selection of that for use which 
is least contaminated with earthy salts ; or the adoption of measures, 
such as boiling, distillation, or Clark's process, for the precipitation of 
these ingredients previous to use. Such measures, and especially emi- 
gration, are often efficacious in the complete removal of goitrous tu- 
mors which are of small size, or have been but a short time in exist- 
ence; and are generally beneficial even in advanced cases. Burnt 
sponge was formerly largely employed, and with reputed benefit, in 
the treatment of goitre ; but Dr. Coindet, of Geneva, after the dis- 
covery of the presence of iodine in sea-water and in marine productions, 
was led to suspect that the efficacy of the burnt sponge was due to the 
iodine which it contained, and to make trial of iodine itself as an anti- 
goitrous remedy. Since that time iodine and its various preparations 
have replaced almost all other internal remedial agents and have en- 
joyed a singular reputation as specifics against this disease. The testi- 
mony, indeed, in favor of the curative influence of iodine is almost 
overwhelming. On the other hand, it must be remarked that, alto- 
gether apart from the influence of iodine, goitre is liable to considera- 
ble fluctuations of size, and when small and recent apt entirely to dis- 
appear; that there is little or no evidence that the drug is efficacious 
in the treatment of exophthalmic goitre, which is structurally identical 
with the endemic form of the disease ; that, notwithstanding the sup- 
posed curative action of iodine, there is no proof that goitre is now less 
prevalent or less severe in goitrous localities than it formerly was ; and 



1 Dr. Fagge, Med.-Chir. Trans., vol. liv. 



542 



DISEASES OF THE VASCULAR SYSTEM. 



that, mixed up with the evidence in favor of the specific virtues of 
iodine, is evidence equally striking in regard to the production of a 
remarkable concurrence of symtoms known by the name of iodism, 
which now seems never to attend the use of iodine, however largely it 
is administered. We must confess that, in our own limited experience 
of the treatment of goitre, iodine has signally failed. But we need 
not limit ourselves to the employment of internal remedies. By many 
persons counter-irritants applied to the surface of the tumor are 
strongly advocated. Among such applications may be enumerated 
iodine paint and other iodic preparations, strong mercurial ointment, 
and blisters or other forms of blistering agents. In some cases (gener- 
ally, however, when the tumor has been of large size or has given indi- 
cations of compressing vital organs), operative measures have been 
resorted to. The tumor has for example been excised, an operation, 
however, of no inconsiderable difficulty and danger, owing to the rela- 
tions of the thyroid body and its enormous vascular supply ; it has 
been treated by passing a seton through its substance and so exciting 
and maintaining inflammation or suppuration in it; and, again, one or 
more of the arteries supplying it have been tied. Each of these opera- 
tions has proved more or less successful in certain cases ; but none of 
them sufficiently successful on the whole to encourage its frequent per- 
formance. It must be observed, however, that cysts of the thyroid 
body admit in most cases of ready and successful treatment, either by 
simple puncture with the discharge of their contents, or by puncture 
with the injection of some stimulating fluid, or by the employment of 
the seton. 

When goitrous tumors are threatening to obstruct the trachea, we 
must be alive to the possibility of the supervention at any moment of 
sudden and fatal asphyxia. What, under these circumstances, can be 
done? Unfortunately, very little. If the enlargement be mainly 
cystic, relief no doubt can be afforded by the puncture of the cyst, and 
the discharge of its contents. If, however, it be solid, as in the main 
it commonly is, it is difficult to see what other resource than trache- 
otomy is left us, and tracheotomy in these cases is both difficult and 
unsatisfactory, for it can rarely be performed below the seat of obstruc- 
tion, it is a formidable operation if effected through the substance of 
the enlarged gland, and if done above the gland, it is necessarily use- 
less, unless it be completed by the passage of a sufficiently long tube 
through and beyond the constricted portion of the trachea. 

The mental condition of cretins, like that of other idiots, admits in 
many cases of amelioration by proper training, for which purpose a 
well-ordered asylum with skilled officials is essential. The improve- 
ment, far more the cure, of the structural lesions which underlie 
cretinism is, however, entirely beyond the resources of our art. The 
prevention of cretinism depends, so far as we know, neither on the 
prevention of marriage between either those who are goitrous or those 
who are in a condition of semi-cretinism, nor on prophylactic measures 
adopted with reference to the young children in whom its presence is 
obvious or merely suspected, but solely on the observance by the 
parents of those special hygienic measures which are efficacious in the 
prevention of goitre. 



DISEASES OF THE SPLEEN. 



543 



DISEASES OF THE SPLEEN. 

Inflammation. 

Causation. — Inflammation of the spleen, at least in an acute form, is 
exceedingly rare, excepting in those cases in which it is due to injury, 
to embolism, to pyaemia, or to the presence of morbid growths or for- 
eign bodies. 

Morbid Anatomy. — Splenic embolism is most frequently a conse- 
quence of valvular disease of the heart. It leads to the formation of 
wedge-shaped blocks, or masses, which vary in size from a cubic inch 
or two downwards, are often multiple, and usually abut on the surface 
of the organ. In the first instance they are mainly hemorrhagic, and 
distinguishable from the splenic tissue by their darker color and greater 
solidity, but soon the coloring matter becomes absorbed, and the masses 
pass through various stages of reddish-brown, yellowish-brown, and 
buff color, until they become almost purely white. Sometimes they 
soften down into a puriform pulp, sometimes undergo actual suppura- 
tion, and sometimes again (especially if small) become absorbed, leav- 
ing depressed cicatrices behind, in which some earthy particles may 
remain imbedded. The presence of these infarctions generally gives 
rise to more or less inflammation in the peritoneal surface over them. 

Pysemic formations present very much the same characters as those 
last described; they are usually, however, more numerous and smaller, 
and their tendency to soften, suppurate, and involve the peritoneum 
covering them is much more marked. 

Splenic abscesses may result from the above and various other causes, 
and, like other abdominal abscesses, may acquire large dimensions, and 
are liable to various terminations. They may open externally through 
the abdominal walls, or they may rupture into the peritoneum, or they 
may discharge themselves into the stomach or colon, or into the left 
lung or pleura. Adhesive inflammation is not uncommon at the sur- 
face of the spleen, and occasionally circumscribed suppuration occurs 
between this organ and some neighboring part, such as the stomach, 
diaphragm, colon, or abdominal walls. 

Symptoms. — In most of the affections now under consideration there 
is little or nothing special, excepting locality, to direct attention during 
life to the spleen as the seat of disease. There may be, indeed, prob- 
ably always is, manifest increase of size of that organ, and there will 
probably be uneasiness, pain, and tenderness. The pain, when severe, 
is mainly due to circumscribed peritonitis, and, from the position and 
relations of the organ, is liable to augmentation during the respiratory 
movements. The recognition of an abscess will depend mainly on its 
attainment of such a size as to form an appreciable fluctuating tumor 
in the splenic region, and on the phenomena which attend and follow 
the process of pointing and the discharge of its contents. In all these 
cases sympathetic vomiting and febrile symptoms of more or less inten- 
sity will almost certainly manifest themselves, and rigors are not un- 



544 



DISEASES OF THE VASCULAR SYSTEM. 



likely to supervene. But it is rare for the splenic affection to be so 
free from complication as to justify us in attributing them to it. 

Special treatment will only be called for when pain is complained 
of, or when an abscess becomes manifest. In the former case, poul- 
tices, fomentations, and leeches are the most obvious applications ; in 
the latter, the case must be treated as one of hepatic or any other 
internal abscess. 

Congestion. 

Causation. — Congestion of the spleen is a condition of common occur- 
rence under a large number of circumstances. It habitually takes place 
during the progress of digestion. Pathologically it is mainly observed : 
first, in dependence on lesions involving mechanical impediment to the 
escape of blood from the spleen, such as obstructive cardiac and pul- 
monary affections, and especially those diseases of the liver in which 
the portal vessels are implicated ; and second, in connection with nu- 
merous acute febrile disorders, of which typhus and enteric fevers, 
pyaemia, and malarious affections may be taken as the types. 

Morbid Anatomy. — In congestion the blood accumulates in the small 
vessels of the spleen and in the intervascular blood-passages, and the 
organ becomes proportionately enlarged. The rapidity with which 
this enlargement may take place is quite remarkable, as also is the 
rapidity with which it may subside. The congested organ may attain 
five or six times its original bulk, retaining, however, its normal form; 
and it usually becomes, in proportion to the amount of blood which it 
contains, pulpy, lacerable, and even diffluent. When the congestion 
is frequently repeated, as in ague, or long continued, as in portal ob- 
struction, the enlargement tends not only to increase, but to become 
permanent. 

Symptoms and Progress. — Simple congestion of the spleen rarely, if 
ever, reveals itself by symptoms, and equally rarely calls for special 
medical treatment. It can, however, often be recognized during life 
(if sought for in those cases in which it is specially liable to occur) by 
the fact of the presence of a manifest tumor in the splenic region. , 
The normal spleen is situated upon the cardiac extremity of the stom- 
ach, its convex surface being in contact with the diaphragm, and no 
part descending below the ribs. Its lowest point is then in close 
proximity with the anterior extremity of the eleventh rib, from which 
point upwards a limited area of dulness, due to its presence, may some- 
times be detected on the left side of the thorax. The enlarged organ, 
however, while partly rising into the chest and increasing the area of 
splenic dulness in that situation, mainly spreads farther and farther 
into the abdominal cavity, taking a course downwards and inwards. 
In cases of extreme enlargement it may occupy nearly the whole of the 
left half of the abdomen, extending from the ribs above to the inguinal 
region below, and from the lumbar region behind to beyond the 
umbilicus, and causing distinct protrusion of the abdominal parietes. 
A splenic tumor is usually readily movable, sinking and rising more 
or less with the respiratory movements, and capable of obvious dis- 
placement under manual pressure ; its anterior edge can generally be 



DISEASES OF THE SPLEEN. 



545 



readily felt, and found to present the characteristic splenic notches. 
If symptoms are present they are mainly a sense of weight or tension 
in the side and more or less tenderness on pressure. It has occasion- 
ally happened that rupture of the greatly congested spleen has taken 
place ; in which case death has occurred with some rapidity, either 
from the escape of blood into the peritoneal cavity, or from peritonitis. 

Treatment. — The treatment of hyperemia mainly consists in the 
treatment of the morbid condition which gives rise to it. 

Hypertrophy of the Spleen. 

Causation. — True hypertrophy is for the most part the consequence 
of long-continued or repeated congestion. It is frequently, therefore, 
found associated with cirrhosis and other chronic affections of the 
liver, and is a common consequence of repeated attacks of malarious 
fever. It is, moreover, a usual attendant upon rickets. But some of 
the most remarkable examples of this affection are furnished by per- 
sons who have never suffered from any of the above disorders, and in 
whom there is no history pointing to the operation of any specific cause. 

Morbid Anatomy. — In true hypertrophy, the organ becomes en- 
larged without undergoing any obvious change in texture ; there is a 
general increase of all its elements in pretty nearly equal proportion, 
and it acquires for the most part a more or less firm fleshy consistence. 
It is in this condition that the spleen attains its greatest volume, 
sometimes filling the left side of the abdomen, from the ribs above to 
the pelvis below, and from the lumbar region behind to some inch or 
two, or more, beyond the umbilicus. It may then measure as much 
as sixteen inches in length, ten inches in breadth, and five or six 
inches in thickness, and weigh ten, twelve, or even twenty pounds. 
It retains its normal shape. 

Symptoms and Progress. — The symptoms due to simple hypertrophy 
are, for the most part, very vague, and difficult to eliminate from those 
of other lesions with which they are frequently associated. There is 
no doubt that persons who are thus affected often suffer from ansemia, 
from discharges of blood (especially from the gastro-intestinal mucous 
membrane), and from abdominal dropsy ; but it is uncertain how far 
these phenomena depend on the hepatic lesion which so commonly 
goes along with splenic enlargement, how far on the splenic disease. 
But, putting such symptoms aside, there is nothing left to indicate the 
presence of splenic hypertrophy beyond the local phenomena to which 
it gives rise. These comprise the manifest existence of a tumor, which 
presents the characters (before described) of enlarged spleen, is tough 
and unyielding in consistence, gives to the patient a sense of weight 
and fulness, especially if he lie upon his right side, and is unattended 
with pain or tenderness on pressure. A venous hum, of more or less 
musical character, may be occasionally recognized on the application of 
the stethoscope over the tumor. The duration of these cases is always 
uncertain, and often much prolonged. In some cases amelioration or 
cure takes place under suitable treatment; in some the organ remains 
stationary, and yet with little manifest deterioration of the patient's 

35 



546 



DISEASES OF THE VASCULAR SYSTEM. 



health ; in many death ensues sooner or later, either from simple 
anaemia and debility, or from these conditions associated with haemor- 
rhage, or dropsy, or some intercurrent affection. 

The treatment of hypertrophy must largely depend on the constitu- 
tional malady which has given rise to it; if it be a sequel of ague, 
quinine or arsenic is indicated ; if the patient be suffering from rickets 
the remedies suitable for that condition must be employed; if there be 
heart, or pulmonary, or renal disease, our efforts must be regulated ac- 
cordingly. In many cases, however, no such clue is furnished ; and we 
must then have recourse to those remedies which the general condition 
of the patient seems to suggest; among the more important of these 
may be enumerated iodine, the iodide and the bromide of potassium, 
iron, quinine, and other tonics. The bowels should be kept freely open, 
if necessary, by the use of mild laxatives. 

Tubercle of the Spleen. 

Tubercular formations are very common, especially in the case of 
young children. The spleen thus affected is usually somewhat enlarged 
and studded more or less thickly with them. They are frequently 
miliary and gray, in which case they may be readily mistaken for the 
Malpighian bodies; usually, however, some of larger size may also be 
detected which have already undergone caseation, and thus furnish a 
clue to the nature of the others. Yellow tubercular masses, irregular 
in form, and varying perhaps from the size of a horse-bean to that of 
a tare, are also not unfrequently discovered, in greater or less abun- 
dance, in association with similar tubercular formations in other parts. 
Occasionally they soften into cavities or lead to the formation of ab- 
scesses. Filamentous processes of false membrane, themselves studded 
with tubercles, are often attached to the surface of tuberculous spleens. 

Tubercle of the spleen can scarcely be recognized during life ; if 
symptoms attend it, they will be such as to suggest either congestion, 
abscess, hypertrophy, or some other than tubercular lesion. 

Morbid Groiuths of the Spleen. 

The various forms of malignant disease affect the spleen with differ- 
ent degrees of frequency and in different modes. First, the peritoneal 
aspect, or the connective tissue about the hilum, may become involved 
by continuity in the course of malignant disease of the peritoneum 
itself, or of the stomach, or of the glands in the neighborhood of the 
stomach, and then the morbid growth either invades the organ from 
different parts of its surface, or runs into its substance along the vessels 
which enter at the hilum ; second, the spleen may have isolated sec- 
ondary growths developed here and there in its substance ; or, third, 
it may be the seat of the primary manifestation of the disease. The 
last alternative, however, is rare. 

Most of the different forms of malignant disease fail to cause any 
very great enlargement of the spleen, or to indicate their presence there 



DISEASES OF THE SPLEEN. 



547 



by special symptoms; and consequently the splenic affection is usually 
overlooked during life. Still carcinomatous growths may attain con- 
siderable size in that organ, and convert it into an irregular and more 
or less indurated mass, readily recognizable during life by palpation, 
and recognizable even (in connection with other phenomena) as a ma- 
lignant growth of splenic origin. It must not, however, be forgotten 
that carcinomatous growths of the great omentum, or other parts of the 
peritoneum in the neighborhood of the spleen, are very apt to simulate 
splenic tumors and to be mistaken for them. These remarks do not ap- 
ply to the case of lymphadenoma. In this, as in simple hypertrophy, 
the spleen undergoes a nearly uniform enlargement, sometimes acquir- 
ing gigantic proportions, but still retaining its natural form and the 
characteristic features by which an enlarged spleen may usually be 
recognized. 

The symptoms of splenic malignant disease are not usually of much 
interest or importance. Those which attend lymphadenoma of the 
spleen will be most conveniently discussed hereafter in connection with 
those due to the same affection of the lymphatic glands. 

Cysts of the Spleen. 

Simple serous cysts are rare in the spleen, and so far as we know, 
quite unimportant. They are occasionally multiple, and associated 
with the development of numerous similar cysts in the liver and spleen. 
Hydatids are more common and far more important. But their course 
and the symptoms to which they give rise are identical (excepting in 
one or two obvious particulars) with those of hydatids of the liver or 
peritoneum, and need not, therefore, be further considered. 

Atrophy of the Spleen. 

Atrophy is exceedingly common, and traceable to various causes. 
In some cases it appears, like cirrhosis of the liver, to be consequent on 
an interstitial overgrowth of connective tissue ; in some, as also occurs 
in the liver, to the investment of the organ in a dense and slowly con- 
tracting fibrous capsule. But, however produced, it is a lesion which, 
so far as we know, causes little or no inconvenience and no symptoms 
by which its existence may be diagnosed. 

Lardaceous Degeneration of the Spleen. 

Morbid Anatomy. — The spleen is perhaps more frequently the seat 
of the lardaceous change than any other part of the body ; but it is 
generally affected in association with one or more of the various other 
organs which are known to be liable to the same change. Lardaceous 
degeneration first affects the minute arterial twigs and the cells external 
to them with which they are in relation, producing in them those 
changes which have been previously described. It is especially apt to 
commence in the Malpighian bodies and in the vessels which are con- 
nected with them. The lardaceous spleen undergoes gradual and 



548 



DISEASES OF THE VASCULAR SYSTEM. 



uniform enlargement, and may attain dimensions nearly as extreme as 
those which are reached by the simply hypertrophied organ. Its cap- 
sule is usually smooth and glistening ; and on section the organ presents 
different appearances according to the degree to which the degenera- 
tion has advanced. In the earlier condition it exhibits those charac- 
ters which have gained for it the name of the "sago" spleen. It is 
thickly studded with grayish translucent rounded masses, which have 
a close resemblance to boiled sago grains, and which are separated 
from one another by a network of still healthy tissue. In the later 
stage these rounded bodies have coalesced, and the spleen is involved 
continuously in its whole extent. In this condition the spleen pre- 
sents on section a nearly uniform grayish translucent, glistening as- 
pect, yields little or no fluid on pressure, and takes the impress of the 
finger like a piece of wax or stiff dough. It is abnormally heavy, 
and readily lacerable, breaking, however, with a somewhat vitreous 
fracture. 

Symptoms. — Lardaceous spleen is always associated with more or 
less anaemia or cachexia, and often with dropsy, tendency to haemor- 
rhage, and other symptoms, for the most part indicative of debility. 
It is never possible, however, to decide to what extent these various 
symptoms depend on the splenic disease — which is always secondary 
to some grave chronic lesion of other organs, and generally associated 
with similar degenerative changes elsewhere — to what extent they are 
referable to these several antecedent or concurrent affections. 

Treatment. — Lardaceous spleen probably never calls for independent 
treatment. Our first efforts must be directed to the cure of the lesion 
out of which the tendency to lardaceous change has arisen ; our next 
to the improvement of the patient's general health by the exhibition of 
iron and other tonics, the administration of abundant nutritious food, 
and attention to all those hygienic measures which are generally bene- 
ficial in cachectic conditions. 



DISEASES OF THE SUPRARENAL CAPSULES. 

The suprarenal bodies are doubtless liable to most of the organic and 
other lesions to which other organs are liable ; but there are only two 
such lesions of them which have any clinical interest, namely, tubercle 
and malignant disease. 

Tubercle. Addison's Disease. {Melasma Addisonii.) 

Definition. — Tubercular infiltration of the suprarenal bodies, together 
with the remarkable group of symptoms which seem always to be as- 
sociated with this lesion, constitutes the malady to which the name of 
" Addison's disease" is now universally applied. When present in its 
typical completeness it comprises in association tubercular destruction 
of the suprarenal bodies, general pigmentary deposition in the rete mu- 



addison's disease. 



549 



cosum, and a remarkable form of progressive asthenia which sooner or 
later ends in death. 

Causation. — Addison's disease occurs much more frequently in males 
than in females, and is rarely if ever met with under the age of ten or 
over that of fifty. Its first symptoms have often been attributed to local 
injury ; and it is certain that it appears occasionally to supervene on 
caries of the neighboring; vertebrae. 

Morbid Anatomy and Patholor/i/. — Miliary tubercles appear in the 
suprarenal bodies, as in other organs, and by their increase in number 
and in size, their coalescence, and the degenerative changes which ensue, 
lead after awhile to their more or less complete destruction. In fatal 
cases of this disease, the disorganization of both glands is usually com- 
plete. They may be diminished in size, but are usually enlarged, 
forming nodulated, rounded, or irregular masses which are adherent to 
surrounding structures by cicatricial tissue. On section they are found 
to consist of dense, grayish, translucent, fibroid material, in the sub- 
stance of which opaque, yellow, cheesy nodules of various sizes are 
imbedded in greater or less abundance. In some cases these have 
undergone earthy infiltration, in some have softened into tubercular 
abscesses. There are no lesions of internal organs or tissues which 
are constantly associated with the suprarenal affection. In a large 
proportion of cases there is absolutely no trace of any such complica- 
tion ; in about half the total number (or rather less) miliary tubercles 
have been met with in the lungs, peritoneum, mesenteric glands, and 
other parts ; and in a small but yet significant proportion of them 
caries of the vertebra? has been present. The condition of the skin 
has a close resemblance to that of a mulatto; it is variously described 
as being of a yellowish-brown, dark brown, greenish-brown, or bronze 
color. This discoloration, which is more or less general, affects espe- 
cially those parts of the body which are most exposed, and those which 
are normally the seat of pigment. Thus, while it affects the face, neck, 
and hands on the whole more intensely than the chest, belly, and legs, 
it is usually especially dark in the axilla?, the areolae of the nipples, 
the umbilical region, the external genital organs and the groins. The 
extensor aspects of the joints are usually more deeply tinged than the 
flexor, and the knuckles, therefore, and backs of the hands are darker 
than the palmar surfaces. The discoloration never presents an abrupt 
margin, but is occasionally spotty, especially on the face and neck ; 
and it is for the most part especially deep upon surfaces which have 
been blistered or superficially destroyed. Deep cicatrices, on the other 
hand, remain for the most part pallid. It must be added that similar 
brown discolorations may generally be observed along the lines of junc- 
tion of the lips, and that spots and patches of the same kind may also 
be discovered on the mucous surface of the cheeks, gums, and tongue. 
The change of color is due, as is that of common freckles, or that of 
the negro's skin, to the accumulation of molecular pigment in the cells 
of the rete mucosum. The hair is said occasionally to share in the 
general superficial pigmentation. 

The relation which exists between the tubercular disease of the 
suprarenal capsules, the discoloration of the skin, and the remarkable 



550 



DISEASES OF THE VASCULAR SYSTEM. 



group of symptoms which attend these lesions, is as yet a matter of 1 
impenetrable obscurity. It has been suggested that the explanation of 
the phenomenon lies in the intimate connection which exists between 
these bodies and the great sympathetic in the abdomen. It has also 
been suggested that the suprarenal bodies, like other ductless glands, 
exert some important influence over the condition of the blood, and that 
it is in the abolition of this influence that the special symptoms of the 
disease are to be sought. But these are, at all events at present, mere 
barren speculations. It has never been shown that disease of the ab- ; 
dominal sympathetic itself induces symptoms resembling those of supra- 
renal disease; nor that the blood or the excretions in Addison's disease 
present any constant departure from the healthy condition. It seems 
probable, however, that the morbid condition of the suprarenal bodies 
is directly or indirectly the source of all the other phenomena of the 
disease. 

Symptoms and Progress. — The chief symptomatic phenomenon of 
Addison's disease is the gradual development of extreme debility, with- 
out commensurate, it may be without appreciable, loss of flesh. The 
patient observes that he is less capable than he formerly was of sustained 
muscular exertion and less disposed for it ; that he cannot walk far 
without suffering from shortness of breath and palpitation, and that if 
he persist in his efforts he falls into a state of prostration which may 
continue on him for many hours or for days. Together with these 
symptoms he suffers from general lassitude and chilliness, and frequent 
sighing and yawning ; he probably loses his appetite and has occasional 
attacks of nausea and vomiting. He perhaps complains also of pains 
across the loins or sacrum, or in the epigastrium and hypochondriac 
regions. There may also possibly be some giddiness and dimness of 
vision. The heart's action becomes extremely feeble ; its sounds per- 
haps scarcely audible, and- the pulse at the wrist small, weak, and i 
sometimes imperceptible. As to rate it may be normal, or quick- ; 
ened, but is often below the average. In the great majority of cases I 
some obvious darkening of the skin goes along with the above symp- 
toms ; sometimes it precedes them in point of time, sometimes follows j 
them, sometimes makes its appearance concurrently with them. It is 
often first observed by the patient's friends, who probably think that 
jaundice is coming on ; but before long it becomes quite obvious to the 
patient himself as well as to those about him. It is first recognized in | 
the face, neck, and hands, and generally manifests itself on the upper 
half of the body earlier than on the lower half. The tint gradually 
increases in intensity, especially in those situations which usually tend 
to become darkest ; but the degree which it ultimately attains differs 
greatly in different cases. In some, though obvious, it is slight up to 1 
the close of life; in others the skin acquires the depth of hue of that of 
a mulatto or negro. In a small proportion of cases no change of color 
whatever ever takes place. The conjunct]' vse in all cases maintain their 
normal pearly lustre throughout. The phenomena above detailed are !, 
associated with many negative features of significant importance. The 
skin remains cool, pliable, and normal in texture ; there is no rise of 
temperature ; the tongue is clean and moist ; and, beyond nausea and j 



addison ? s disease. 



551 



sickness, there are no indications whatever of inflammation or of or- 
ganic disease of the chylopoietic viscera; the bowels are regular; and 
the urine is scanty but normal in appearance and constitution, except- 
ing that urea is for the most part largely reduced in quantity. 

With the progress of the case the debility increases. The debility 
is not always obvious as the patient lies quiet in bed (to which he is 
probably before long confined) but especially manifests itself in the 
supervention of alarming prostration after any unwonted effort. The 
nausea and sickness increase, but are liable to variation, and may even 
disappear for awhile; they are not unfrequently associated with good 
appetite. The patient suffers occasionally from headache in addition to 
his other pains, and complains at times of chilliness, his hands, feet, 
and nose probably becoming cold and livid from imperfect circulation; 
the temperature in the axilla not unfrequently falls a degree or more; 
sometimes, on the other hand, it rises one, two, or three degrees; and 
although no actual paralysis may be present, he is apt to complain of 
numbness in his lower extremities and to believe that he has lost the 
use of them. Towards the close of the disease the breath and the skin 
often yield an offeusive cadaveric odor, and the skin occasionally be- 
comes furfuraceous ; the patient grows apathetic, disinclined to make 
any unnecessary movement, or even to reply to questions; and, although 
now and then becoming delirious, usually remains conscious to the last. 
Death results from asthenia, and is sometimes brought on by a sudden 
attack of faintness, which may be referable to some apparently trivial 
exertion. 

It has been assumed in the foregoing account that the patient is free 
from tubercle of other organs or from vertebral caries. The presence 
of such complications tends more or less to mask the phenomena due 
to the suprarenal disease. It is important, however, to note that, 
even in complicated cases, the complications are rarely so extensive or 
so serious as of themselves to cause death, or so engrossing by the 
phenomena to which they give rise as materially to obscure the diag- 
nosis of the suprarenal lesion. It might, indeed, almost be said that 
the presence of tubercles in the lungs and elsewhere, or of caries of the 
spine, should bring with it a thought as to the possible presence of 
suprarenal complication. 

There is unfortunately no reason to doubt that Addison's disease is 
always ultimately fatal. The duration of the malady is, however, sub- 
ject to considerable variation. It is probably not possible in any case 
to ascertain the exact commencement of the disease ; there are, indeed, 
good reasons for believing that the process of suprarenal degeneration 
is far advanced before the clinical signs of the affection reveal them- 
selves. Counting, then, from this latter date, the malady is sometimes 
remarkably rapid in its progress, proving fatal in the course of two or 
three weeks, while in other cases it is prolonged for several years. 
More commonly it terminates fatally within a year. It is very im- 
portant, however, to observe that the course of patients with this dis- 
ease is not always progressively from bad to worse ; but that they are 
liable to attacks of nausea and prostration, so severe as to threaten life, 
alternating with periods of greater or less duration in which they gain 



552 



DISEASES OF THE VASCULAR SYSTEM. 



flesh, and seem to be fairly comfortable and hopeful ; that many subjects 
of it doubtless fight against advancing weakness, not admitting them- 
selves to be out of health, until possibly one of those sudden failures of 
the vital power to which they are liable compels them to yield ; and, 
lastly, that such sudden seizures may often be warded off by the scrupu- 
lous avoidance of mental or bodily exertion, exposure to the influence 
of cold, and errors of diet, and thus the patient's life be greatly pro- 
longed. The debility induced by suprarenal disease is in this respect 
verv much like that which attends saccharine diabetes. 

Treatment. — The cure of Addison's disease is beyond our power ; and 
all, therefore, that we have to do is, by endeavoring to counteract the 
various secondary phenomena of the disease, to prolong life and render 
it endurable. It is of the utmost importance to maintain the patient at 
rest both as regards mind and body, and to keep him warmly clad and 
in an apartment of agreeable and moderate temperature. Sickness and 
irritability of the stomach should be relieved by appropriate remedies; 
tonics (the nature of which must be determined by the condition of the 
patient's digestive organs) should be administered ; and he should be 
nourished and supported by wholesome and nutritions food, ,with such 
a proportion of alcoholic stimulants as may seem to be needed. 

Morbid Growths of the Suprarenal Capsules. 

The various forms of malignant disease are all apt to attack the 
suprarenal bodies secondarily; and in rare cases these organs are the 
seat of their primary development. When the disease is secondary, 
the suprarenal growths rarely attain a large size, and nothing probably 
occurs during the whole course of the case to direct attention to them. 
When, however, the disease is primary in them, they may form tumors 
as large as a cocoanut, which from their size and situation may be 
easily recognized during life. It would be difficult, if not impossible 
to distinguish such tumors from renal tumors; they occupy, in fact, 
exactly those situations which tumors originating in the upper part of 
the kidneys would occupy. They form rounded or lobulated immova- 
ble masses, springing from the posterior part of the abdomen, and are 
usually crossed by the ascending or descending colon which they push 
forwards in their growth. Their development is sometimes attended 
with frequent paroxysms of agonizing pain, and always with the emacia- 
tion, debility, cachexia, and other phenomena which are associated with 
the progress of visceral malignant disease; but never, so far as is known, 
with the specific symptoms of Addison's disease. 



DISEASES OF THE LYMPHATICS. 

There are probably no organs or tissues of the body the pathological 
relations of which are more important than those of the lymphatic 
vessels and glands ; no organs which are more frequently involved in 



DISEASES OF THE LYMPHATICS. 



553 



the course of diseases originating in other parts; none, the proper dis- 
eases of which more profoundly affect the general organism. Their 
affections are, however, for the most part, so intimately connected with 
those of other organs, or with the so-called "general" diseases, that 
the discussion of these latter necessarily involves that of their lymphatic 
complications. It is needless, therefore, notwithstanding its surpassing 
interest and importance, to enter here at any length upon the subject 
of the diseases of the lymphatic system. 

Inflammation of the Lymphatics. 

Causation. — Inflammation of the lymphatics is, no doubt, sometimes 
primary, in the sense in which idiopathic pneumonia is primary, and 
sometimes the consequence of blows or other forms of direct mechanical 
violence; in the great majority of cases, however, it arises secondarily 
to some local inflammation, or is the consequence of some irritant acting 
through the blood. 

Morbid Anatomy. — If the glands be secondarily affected, those only 
suffer which lie next above the inflamed area, in the line of the lym- 
phatic vessels originating in it. In this case some irritating matters, 
probably the products of inflammation, are taken up by the radicles of 
the lymphatic vessels, and carried upwards by them until they become 
arrested in their progress by the lymphatic glands. During the passage 
of these matters the vessels themselves sometimes inflame, their parietes 
become thickened and vascular, and the connective tissue surrounding 
them congested and infiltrated; and thus their course becomes indicated 
by red and more or less tumid bands. Sometimes, indeed, abscesses 
form in their course. On the other hand, lymphatic vessels very fre- 
quently convey, without injury to themselves, matters which excite 
violent inflammation in the lymphatic glands, and ulterior mischief of 
the gravest character. Inflammation of the lymphatic glands is marked 
by hyperemia, succulence, softening and swelling, and an excessive de- 
velopment of cells resembling those natural to the healthy organs. 
Suppuration sometimes ensues, and occasionally (especially among lax 
tissues such as that of the axilla) enormous abscesses result. In some 
instances the inflammation assumes a chronic character, and ends in the 
induration, contraction, and atrophy of the glands. The nature of the 
inflammation and its tendency in respect of result, differ in accordance 
with the characters of the local inflammation, or of the specific disorder 
to which it owes its origin. 

Symptoms and Progress. — The symptoms due to lymphatic inflam- 
mation are principally swelling, heat, pain, and tenderness in the course 
of the affected vessels and in the affected glands, with visible hyperemia 
in the situation of such as occupy a superficial position, and febrile 
symptoms of more or less severity. Indeed the febrile symptoms are 
generally severe, apparently out of all proportion to the extent and im- 
portance of the inflamed tract, and are not unfrequently attended with 
rigors. Their severity is doubtless due in no small degree to the fact 
that the inflamed lymphatics are in direct communication with the 



554 



DISEASES OF THE VASCULAR SYSTEM. 



blood, and are constantly pouring the products of their inflammation 
into it. 

Treatment. — For the general treatment of inflamed glands (supposing 
them to need any apart from the affection which gave them origin) no 
rules need be laid down beyond such as should guide us in the treat- 
ment of tonsillitis and other forms of local inflammation. For local 
treatment, leeches, fomentations, poultices, and in some cases cold ap- 
plications, comprise the most important agents. When the inflamma- 
tion becomes chronic, counter-irritants, iodine paint, strong mercurial 
ointment, and blisters will probably be more efficacious. 

Tubercle of the Lymphatics. Scrofula. 

Morbid Anatomy. — It is not easy to draw a distinct line between tu- 
bercle of the lymphatic glands and that enlargement of them which so 
commonly occurs in so-called "scrofulous" children. 

But however different these affections may appear to be from one 
another in their early stages, it is certain that in both there is an equal 
tendency for the affected glands to undergo speedy caseous degenera- 
tion, and to be converted into opaque yellowish, friable, fattily-degen- 
erated masses, which, according to their situation and other attendant 
circumstances, either soften or suppurate, or become converted into en- 
cysted mortary or cretaceous masses. Softening with ulcerative de- 
struction especially takes place in connection with mucous surfaces ; 
softening with formation of abscesses in the case of the glands which 
are superficially placed; cretaceous changes in the glands of the medias- 
tinum and mesentery, and in others which lie deep in the interior of 
the body. 

Symptoms and Progress. — The symptoms of tubercular or scrofulous 
disease of the glands are rarely characteristic except when the glands 
affected are so situated as to admit of ready examination. They are 
then as a rule scarcely painful or even tender, and are usually indolent 
in their progress ; suppuration is long delayed and slow to reach the 
surface ; and even after the contents have been evacuated the abscess 
continues to discharge for an indefinite time ; and when at length the 
cavity becomes closed, the scar which remains is ragged and unsightly. 
The general symptoms are those of debility and constitutional weakness. 

Treatment. — The general treatment for cases of scrofulous disease of 
the glands consists in the use of tonics, cod-liver oil, good nourishing 
diet, change of air, and generally careful attention to hygienic measures. 
The local treatment belongs mainly to the surgeon. So long as the 
glands are neither painful nor suppurating, it is probably best to trust 
wholly to constitutional treatment ; when, however, there is pain or 
suppuration, poultices or fomentations are demanded, and, in the latter 
case, sooner or later the surgeon's knife. 

Morbid Growths of the Lymphatics. Mediastinal Tumors. 

Morbid Anatomy. — 1. Malignant disease, commencing elsewhere, in- 
variably soon attacks the lymphatics, and in the first instance those 



DISEASES OF THE LYMPHATICS. 



555 



glands which lie nearest to the primary spot of disease, between it and 
the thoracic duct. These glands indeed generally become rapidly and 
extensively involved, forming large tumors, which sooner or later coal- 
esce with one another, and implicate in the progress of their growth 
the surrounding tissues. Thus, in malignant disease of the tongue or 
mouth, the glands at the angle of the jaw first suffer ; when the breast 
is the source of infection, the axillary glands; when the lungs, the 
bronchial glands ; when the stomach or bowels, the mesenteric or re- 
troperitoneal glands ; when the penis, the glands of the groin ; when 
the testicle, those lying in the lumbar region. In some cases the in- 
volvement of the lymphatics forms a still more obvious factor of the 
disease, and it may be primary in them. The most remarkable exam- 
ple of this kind is furnished by lymphadenoma, which (as has been be- 
fore pointed out) primarily affects not only the lymphatic glands but 
the lymphatic tissues throughout the whole system, and though not 
necessarily limited to these in its ulterior development, commits its 
ravages mainly upon them. 

2. Mediastinal Tumors. — Malignant tumors are of common occur- 
rence in the mediastina, and are not unfrequently primary in this situa- 
tion. It is not always easy to determine in what tissue they have 
originated. It is certain, however, that they often appear to start from 
the lymphatic glands in the posterior mediastinum, and from that part 
of the anterior mediastinum in which are situated the remains of the 
thymus gland. It is not improbable that they also arise in the sub- 
stance of the connective tissue. The nature of the disease varies in 
different cases ; it is sometimes carcinoma, but probably much more 
frequently is either sarcoma or lymphadenoma. The growth gradually 
increases in bulk, and, even if it did not originate in the lymphatic 
glands, very soon involves them, and gradually implicates all the sur- 
rounding parts. Thus by degrees it may invade all the tissues of the 
anterior and posterior mediastina, surrounding and involving the 
parietal pericardium and the neighboring portions of the parietal 
pleurae ; or it may involve the roots of the lungs, extending along the 
bronchial tubes and vessels into the substance of the lungs, or impli- 
cating the neighboring portions of these organs by continuity, and 
probably forming large tumors in them ; or it may extend into the 
cardiac walls, either infiltrating their substance or forming distinct 
growths. Further, it is apt sooner or later to implicate the trachea, 
the bronchi, or the oesophagus; the innominate veins, or the cava; or 
the recurrent laryngeal nerves ; or to involve the lymphatic glands 
above one or other clavicle, or to lead to the development of tumors in 
the ribs or soft tissues of the thoracic walls. The dimensions which 
mediastinal tumors attain are sometimes enormous; they may become 
as large as an orange, a cocoanut, or a child's head ; moreover in their 
growth they tend to cause much compression and much displacement 
of parts. The heart, for example, may be carried into the right axilla, 
or even into the left. 

Symptoms and Progress. — 1. The general symptoms caused by ma- 
lignant disease of the lymphatics are mainly those of malignant disease 
generally ; when, however, these organs are implicated, the morbid 



556 



DISEASES OF THE VASCULAR SYSTEM. 



r 



process has already begun to exert a specific influence over the system, ' 
and the so-called "cancerous cachexia," if not previously manifest, be- 
comes for the most part very rapidly developed. The local symp- 
toms are those of a more or less painful rapidly growing tumor, the 
direct results of which depend upon its situation. 

2. The symptoms to which mediastinal tumors may give rise are 
necessarily very various, and mainly depend on their seat and bulk and 
the particular intrathoracic organs which they implicate. Their symp- 
toms, indeed, are almost identical with those which are caused by in- 
trathoracic aneurisms. The early symptoms are vague, but not un- 
frequently include more or less progressive anaemia, debility, and 
shortness of breath. The more characteristic phenomena slowly super- 
vene, their sequence, however, varying in different cases. Sometimes 
the veins become obstructed ; those of one half of the head and neck 
and face and of the corresponding shoulder, arm, and side of the chest, 
or those of both sides equally become dilated, tortuous, and full ; and 
the implicated regions acquire a ghastly, livid, or congested aspect, 
and become more or less puny or oeclematous. This limited congestion 
and oedema are very striking phenomena, especially when, as generally 
happens, the rest of the body is or is becoming pallid and wasted. 
Sometimes the respiratory organs become involved ; the patient has 
difficulty of breathing, with cough, and probably expectoration. In 
some cases the symptoms are much like those of slowly advancing 
bronchitis; in some, owing to implication of the trachea or recurrent 
laryngeal nerves, like those of laryngeal disease, and attended with 
hoarseness or aphonia, and attacks of suffocative cough ; in some, owing 
to the formation of tumors in the lungs or to the supervention of 
pneumonia or pleurisy, like those which have been described as be- 
longing to these affections. Sometimes the symptoms are mainly 
cardiac, and simulate those due to valvular disease. Sometimes the 
patient has difficulty or pain in swallowing. And often, in connection 
with the cardiac, pulmonary, or laryngeal symptoms, or those of 
venous obstruction, he complains of vertigo, headache, and even of 
occasional attacks of momentary unconsciousness or of slight convul- 
sion. It is not uncommon to have blood in the expectoration, and 
late in the disease the sputa are apt to be abundant, muco-purulent, 
and fetid. 

The diagnosis of the disease is often largely aided by physical ex- 
amination ; by the gradual extension of the area of precordial dulness, 1 
by the increase of resistance experienced on percussion, by the dis- 
placement of the heart or lungs, or by the supervention of pulmonary 
consolidation or pleural effusion, and the modification in the auscul- 
tatory phenomena which these several affections entail. It is further 
aided by the presence of localized dilatation of veins in the thoracic 
parietes. The most important indications, however, are thus fur- 
nished by the development of tumors in the thoracic parietes or above 
the clavicles. 

It must not be forgotten that in the course of mediastinal disease 
secondary tumors are apt to arise in other parts of the body; and that 
occasionally these secondary tumors cause more striking symptoms than 



DISEASES OF THE LYMPHATICS. 



557 



does the primary disease, which is consequently apt to be overlooked. 
Thus it is not uncommon for secondary tumors to become developed in 
the brain, and for the patient to die with cerebral symptoms. 

It is obvious that the symptoms due to mediastinal growths are 
mainly made up of the symptoms due to implication of the various im- 
portant organs which occupy the mediastina or abut upon them; and 
in order that the reader may have a clear conception of their variety 
and importance, and a thorough picture of the disease, we must refer 
him to the descriptions elsewhere given of the phenomena referable to 
lesions of the several organs here adverted to. 

It need scarcely be added that mediastinal tumors are progressive in 
their course, and always sooner or later prove fatal. The causes of 
death are various. 

Treatment. — Palliative measures only are as a rule available in malig- 
nant disease involving the lymphatic glands. Accessible glands occa- 
sionally admit of removal with temporary benefit. 

Leucocythemia. 

All who recognize the lymphatic tissue, whether it be situated in the 
lymphatic glands or in the vascular glands, or scattered in less obvious 
masses throughout the organism, as the source of the corpuscular ele- 
ments of the blood, will be prepared to believe that morbid conditions 
involving this tissue must exert a more or less obvious deleterious in- 
fluence over the composition of that fluid, and through it over the 
general nutrition of the tissues. It is probably through the lymphatic 
glands mainly, if not entirely, that the poisonous principles of syphilis, 
of tubercle, of cancer, and of various other malignant diseases, gain en- 
trance into the blood, and thus infect the system at large; and it is not 
improbable that the specific poisons of the various infectious fevers 
generally pass into the system through the same portals. These, how- 
ever, are matters which belong rather to general pathology, or to the 
various diseases that are included in the several categories here adverted 
to, than to the present discussion. Our purpose, indeed, now is mainly 
to consider the consequences, as regards the composition of the blood 
and the general health, which result from lymphadenoma or lympho- 
sarcoma of the blood-producing organs, and mainly of the lymphatic 
glands and of the spleen. 

Pathology and Morbid Anatomy. — The anatomical features of this 
affection have been already discussed at some length, under the head of 
lymphadenoma, in an earlier portion of the work. We have pointed 
out that lymphadenoma is a form of malignant disease especially apt to 
attack the lymphatic glands and the spleen, sometimes the one, some- 
times the other, but more frequently both, and many other organs and 
tissues at the same time or consecutively. We have adverted also to 
its influence on the condition of the blood, which is at once curious and 
various. In a considerable number of cases (to which Dr. Wilks has 
given the name of anaemia lymphatica, Trousseau that of adenia) the 
disease is attended in its progress with gradually increasing but simple 
anaemia, the blood becomes progressively more and more watery, and 



558 



DISEASES OF THE VASCULAR SYSTEM. 



the blood-corpuscles (red and white in equal ratio) gradually disappear. 
In other cases, which are undistinguishable anatomically from these, and 
in which the general symptoms and progress of the disease are as nearly 
as possible identical, progressive anaemia also takes place, but it is an 
anaemia distinguishable from the former by the fact that, while the red 
corpuscles disappear, the white multiply until, in extreme cases, they 
nearly equal their red companions in number, and after death are not 
unfrequently found aggregated in pale clots, or in thick creamy masses 
in the terminal branches of the pulmonary artery, in the cavities of the 
heart and elsewhere in the course of the systemic circulation. The con- 
dition known as leukaemia or leucocythemia becomes established. 

Symptoms and Progress. — The termination of lymphadenoma, like 
that of all other forms of malignant disease, is invariably fatal, but its 
duration is various, and probably ranges between six months and two 
or three years. It not unfrequently first reveals itself by the gradual 
painless enlargement of some of the lymphatic glands, most frequently 
those of the neck, or by splenic hypertrophy. These tumors may go 
on- increasing for some time, and may become complicated by the en- 
largement of many other groups of lymphatic glands and of other 
internal organs, before the patient appears to suffer materially in his 
general health. But gradually he becomes anaemic, loses flesh and 
strength, becomes incapable of exertion, short-breathed, and liable to 
palpitation. And, after awhile, the morbid growths still extending 
and forming tumors in various parts of the body, and debility increasing, 
he loses appetite, probably suffers from diarrhoea, becomes in a greater 
or less degree anasarcous, or has accumulations of fluid in the serous 
cavities, and becomes liable to haemorrhages, which take place some- 
times into the subcutaneous or subserous tissue, sometimes from the 
various mucous surfaces, and especially from that of the nose. Fever 
is not an essential feature in the progress of the disease, and when pres- 
ent is liable to considerable variations ; in some cases it is absent, or 
nearly so, from first to last ; in some fever of a hectic type is developed 
in the later stages of the disease ; in some the patient is liable to occa- 
sional febrile exacerbations coming on at irregular intervals, and appa- 
rently coincidently with its fit of activity in the development of the 
morbid growths. The urine generally is healthy, except that towards 
the close of life it is apt to become scanty, and loaded with urates and 
free uric acid. Death in some cases is due simply to the debility which 
the disease gradually induces, and which occurs all the more speedily 
if haemorrhages have taken place. But in many cases it is caused less 
by the general anaemia and loss of strength than by the direct influence 
of one or more of the tumors on important organs. 

Treatment. — The treatment of lymphadenoma, whether attended or 
not with leukaemia, is, like that of carcinoma, altogether beyond the 
resources of our art. We can only relieve symptoms as they arise, 
and promote the health of the patient by attention to diet and by 
hygienic management. 



DISEASES OF THE LYMPHATICS. 



559 



Obstruction and Dilatation of the Lymphatic Vessels. 

Morbid Anatomy and Symptoms. — Obstruction in the course of the 
thoracic duct may be caused by the pressure of tumors upon it, or by 
disease of its walls, or by a morbid condition of its contents ; but is of 
very rare occurrence. It might be supposed that it would lead to very 
rapid innutrition and, at the same time, to general dilatation of all the 
lymphatics excepting those of the right upper extremity and corre- 
sponding part of the head and neck and thorax. Experience, however, 
and experiment would seem to show that sudden obstruction usually 
results rather quickly in great overdistension of the lower part of the 
duct, and especially of the receptaculum chyli, which presently ruptures 
with extravasation of its contents into the retroperitoneal tissue ; and 
that sloioly induced obstruction may be compensated by the enlargement 
of existing communications between the obstructed left and the still 
pervious right duct. 

Obstruction occurring in a group of lymphatic glands in consequence 
of disease going on in them, or in the group of lymphatic vessels 
entering or leaving them, in consequence of pressure upon them or of 
their involvement in disease, always leads in the first instance to stasis 
and accumulation of lymph within the tributary vessels, which conse- 
quently become dilated, and subsequently to similar accumulation 
within the lymphatic spaces and to their disproportionately large ex- 
pansion. The lymph-channels, indeed, and the tissues generally become 
surcharged with lymph — a clear or milky yellowish alkaline fluid of a 
sickly odor, which contains albumen, fibrinogen, and lymph-corpuscles, 
and among other occasional constituents sugar and molecular fatty 
matter, and which, like the plasma of the blood, coagulates more or 
less perfectly on removal from the body. The result is the develop- 
ment of what is often termed solid oedema or leucophlegmasia of the 
implicated portion of the body. This becomes swollen and tense, and 
of a pale waxy hue, but does not pit on pressure as in ordinary venous 
dropsy. And, further, if the condition be of long duration, and espe- 
cially if it be developed in infancy when the organism is undergoing 
rapid growth, the tissues of the affected region — not only connective 
tissue, but muscles, bones, and skin — all become distinctly hypertrophic. 
This obstruction and dilatation of the lymphatics is the essential feature 
or an important factor of several well-recognized pathological condi- 
tions. A particular form of enlargement of tongue, usually congenital, 
in which the organ tends to grow, to protrude from the mouth, and to 
interfere by its bulk with the growth of the jaws, has been shown by 
Yirchow to be due to lymphatic obstruction. The tongue is honey- 
combed with dilated lymph-channels, and the seat of consequent over- 
growth of all the tissues of the organ inclusive of the muscular substance 
and of the papillary surface. The upper extremity has occasionally 
become, from accidental circumstances, similarly affected. But the 
most frequent, and, on the whole, the most interesting example of such 
obstruction and its consequences is afforded by the lower extremity and 
the adjoining portions of the abdomen and genital organs, in the con- 



560 



DISEASES OF THE VASCULAR SYSTEM. 



dition we have already described under the name of elephantiasis tele- 
angiectodes. The last morbid condition characterized by dilatation of 
the lymphatics to which we may refer is elephantiasis Arabum, a dis- 
ease which, like the last, is more fully discussed in another part of this 
volume. 

Treatment. — It is obvious that no medicines are competent to relieve 
the various consequences of obstruction of the lymphatics ; recourse can 
onty be had to mechanical or operative measures. In enlargement of 
the tongue, portions of the organ have been excised with benefit; as 
also have portions of the prepuce when that structure has become 
hypertrophied. 



AKZEMIA CHLOROSIS. 

Definition. — Anaemia, or, in other words, diminution of the solid 
constituents of the blood and in particular of the red and white cor- 
puscles, attended with more or less considerable pallor of the general 
surface and of the mucous membranes, with palpitation, feebleness, 
and rapidity of the pulse, panting respiration, sighing and yawning, 
headache, restlessness, functional disturbance of the organs of sight and 
hearing, tendency to faint and general debility, is a frequent complica- 
tion or result of many morbid conditions ; of the dyscrasi?e, for ex- 
ample, connected with tuberculosis, malignant disease, syphilis, and 
malarious affections, and of the haemorrhages, more or less frequent 
and more or less copious, which take place under various circumstances 
from one or other of the mucous tracts. 

Chlorosis is a special form of ansemia, limited almost exclusively to 
young women, coming on without obvious cause, independently, so 
far as we know, of pre-existing disease, attended with characteristic 
symptoms, and almost without exception terminating sooner or later 
in convalescence. 

Causation. — Chlorosis, or a condition closely resembling it, is occa- 
sionally met with in men ; it also (but rarely) affects women of mature 
age or those in whom menstruation is disappearing. It is, as above 
stated, especially a disease of young females, of females ranging in age 
from the period of commencing puberty to about twenty-five. Many 
causes have been assigned for it, such as deficient or unsuitable diet, 
unwholesome habitations, sedentary habits and want of fresh air, late 
hours, emotional affections, masturbation, and especially functional 
uterine or ovarian disturbances. It may be readily admitted that some 
of these conditions may be predisposing causes of chlorosis, it is cer- 
tain that some of them may be consequences of it, but it is very doubt- 
ful if any of them can lay claim to being the exciting cause. The 
nature of this last, indeed, is still veiled in mystery. 

Symptoms and Progress. — Chlorosis generally first reveals itself by 
gradually increasing paleness of the surface, palpitation, breathlessness 
on exertion, and loss of muscular power, and by the supervention of 
more or less gastrodynia and impairment of the digestive functions, 



ANJEMIA — CHLOROSIS. 561 

without loss of flesh. With these phenomena, however, many others 
become associated sooner or later. The loss of color usually becomes 
extreme, the general surface assumes a white or sallow wax-like appear- 
ance, the face, indeed, may present a greenish tinge — whence the name 
of the disease. The loss of color is, for the most part, chiefly obvious 
in the palpebral conjunctivae, and in the lips and gums, which become 
in some cases scarcely distinguishable in tint from the skin itself. It 
may be pointed out that, even in extreme cases, a fallacious bloom may 
appear in the cheeks under the slightest emotional excitement. Palpi- 
tation is a prominent symptom, and always painfully apparent to the 
patient herself ; it is rarely absent, and is always aggravated either by 
mental excitement or by bodily exercise ; the rapidity with which the 
heart's contractions succeed one another is sometimes extraordinary, 
and not unfrequently their rhythm becomes markedly irregular. The 
development of abnormal sounds in the heart and bloodvessels, inde- 
pendent of organic lesions, is of common occurrence and highly charac- 
teristic. A soft systolic murmur is frequently to be heard over the 
situation of the aortic or pulmonic valve, and along the course of the 
ascending arch and innominate artery. Murmurs, coincident with the 
cardiac systole, may be developed more readily than natural by pressure 
in the course of the subclavian, carotid, and other large arteries. And, 
lastly, continuous murmurs, more or less musical, and varying from a 
feeble hissing to a deep droning (the bruit de diable), may be readily 
evoked by the pressure of the stethoscope on the veins of the neck, more 
especially on the right side. The respirations are usually more rapid and 
shallow than in health, and occasionally become extraordinarily fre- 
quent, particularly under the influence of slight bodily exertion or 
emotional disturbance; and the patient consequently complains of 
shortness of breath and inability to exert herself. There is usually 
some impairment of the digestive functions, with uneasiness, or weight 
after food, flatulence, loss of appetite, and pain more or less severe and 
varying in character, either in the epigastric region or between the 
shoulders, in the left hypochondrium, or some neighboring part. It is 
apparently in chlorotic girls that perforating ulcer of the stomach is 
most common, on which account their dyspeptic symptoms must always 
be regarded with suspicion and treated with care. The bowels are 
usually constipated. The urine, for the most part, is abundant, pale, 
and of low specific gravity. There is not unfrequently leucorrhoea ; 
and although the menstrual function in some cases continues to be 
normally performed, it is usual ly at fault. The flow is sometimes regular 
but scanty ; sometimes profuse or too frequent, or attended with severe 
pain ; most commonly there is amenorrhoea. Trousseau points out, 
and probably with truth, that the sexual appetite is diminished rather 
than (as is often asserted) increased. The muscular system becomes 
generally enfeebled ; but the subcutaneous fat undergoes little or no 
diminution, sometimes, indeed, becomes increased, so that the patient, 
as a rule, presents more or less embonpoint. Some degree of anasarca, 
especially in the low T er extremities, occasionally supervenes in the course 
of the disease. The nervous phenomena which are apt to attend chlo- 
rosis are many and various. There is usually more or less listlessness, 

36 



562 



DISEASES OF THE VASCULAR SYSTEM. 



inability of application to any pursuit or even train of thought, low- 
ness of spirits, and irritability of temper. Usually, also, chlorotic 
girls suffer much from neuralgic pains, sometimes in the face and head, 
sometimes in the intercostal muscles, sometimes in the internal organs 
or in the extremities. Again, they not unfrequently become hysterical, 
have depraved appetites, or suffer from paralysis or convulsions, or even 
become maniacal. 

It is rare for chlorosis to terminate fatally, or even to lead to the 
development of tuberculosis or any other organic disease, excepting, 
perhaps, ulcer of the stomach. The patient generally recovers in the 
course of a few weeks or a month, but is liable to have relapses. 

Pathology. — The pathology of chlorosis is not at all understood. 
Trousseau regards the disease as a neurosis, looking upon the morbid 
condition of the blood as secondary to the nervous affection. Some, 
however, would consider the reproductive organs, others the chylopoietic 
viscera, as being primarily at fault. It is natural to refer the diminu- 
tion of the corpuscular elements of the blood to some functional dis- 
turbance or organic lesion of the lymphatic tissues ; but unfortunately 
nothing has yet been detected in their condition to justify this view. It 
is attempted to make a distinction between ordinary forms of anaemia 
and chlorosis by reference to the composition of the blood. Ordinary 
anaemia, it is said, is characterized by the diminution in equal propor- 
tion of all the solid constituents of that fluid, whereas in chlorosis it is 
the corpuscular elements which are alone deficient. It is clear, how- 
ever, that this distinction can be of little value; for it is well known 
that when anaemia is caused by abstraction of blood, the corpuscles and 
other organic principles being removed in equal proportion, the albu- 
minous and other such matters are far more speedily restored to the 
blood than the corpuscles, and that hence (whatever may have been 
the patient's condition at first) a time speedily arrives in which the blood 
will present the assumed typical characters of chlorotic blood. 

Treatment. — It is no doubt important in the treatment of chlorosis 
to obviate all possible sources of ill-health, and especially to secure for 
the patient change of scene, good air, moderate exercise, early hours, 
innocent amusement, and wholesome diet. But of far greater impor- 
tance than these is the administration of iron. This metal, indeed, 
appears to be almost a specific remedy in this disease. Different au- 
thorities recommend different preparations, but they are probably all 
(if given in equivalent doses) equally efficacious. They are generally 
best administered in combination with some vegetable bitter or stom- 
achic, such as quinine, cinchona, or calumba, and in association with 
occasional purgatives, such as aloes and myrrh pills, to obviate the 
obstinate constipation which is so often present. The form in which 
iron should be given must be determined by the special circumstances 
of the case. If dyspeptic symptoms are predominant, the tartrate of 
iron, in combination with an alkali, and calumba or quassia, may be 
most suitable. It may even, under such circumstances, be well to delay 
the use of iron until some amendment in the condition of the stomach 
has been obtained by other measures. If menorrhagia be present, the 
perchloride of iron or the sulphate, in combination with mineral acids, 



PURPURA. 



563 



may prove especially serviceable. Zinc is believed by some to have 
similar virtues to those of iron. In a large number of cases the fer- 
ruginous treatment cures not only the chlorosis, but the various corn- 
plications, dyspeptic and uterine, which accompany the chlorosis; but 
that is not always the case, and just as it is frequently necessary to treat 
the dyspepsia directly, so it may be essential to direct our treatment to 
the cure of the uterine derangement. 



PURPURA. 

Definition. — Extravasations of blood, in the form of points, pete- 
chias, vibices, or ecchymoses, are not uncommonly observed beneath 
the surface of the skin in various forms of disease, and under many 
other conditions, and are then often termed purpuric. Not unfre- 
quently these subcutaneous extravasations (especially if due to consti- 
tutional disorders) are associated with similar extravasations into the 
solid organs, beneath the serous and the mucous membranes, and with 
more or less abundant escape of blood from the surfaces of these mem- 
branes. Such extravasations are especially common in the course of 
typhus, small-pox, measles, scurvy, obstructive heart affections, and liver 
disease, and are also met with in scarlet fever and diphtheria, in pyae- 
mia and in embolism. They, further, occasionally complicate certain 
skin diseases, more especially some of the forms of erythema and urti- 
caria, and may be induced in certain regions by mere exposure to at- 
mospheric influences. But to none of these affections, however severe 
they may be, can the term purpura be properly applied. 

Purpura, in the strict sense of the term (the morbus maculosus 
Werlhofii of the Germans), is the name given to an affection charac- 
terized by such hemorrhages as have been above specified, but uncon- 
nected, so far as we know, with any local mischief or any general spe- 
cific disease. 

Causation. — The causes of purpura, or the conditions under which 
it arises, are exceedingly obscure. It occurs at all ages, but mostly in 
young children of both sexes. It is very frequently observed amongst 
those who are sickly, or underfed, or surrounded by unwholesome sani- 
tary conditions, but it is also met with amongst the robust and healthy- 
looking, and those whose hygienic and other circumstances appear to 
be unexceptionable. ' It is certainly not due to insufficiency of vege- 
table food, nor has it been traced to any special dietetic default. It 
may be added that it is very apt to recur, and that it is not uncommon 
to find a child (and apparently a healthy one) having periodic relapses 
at intervals of three, six, or even twelve months. 

Symptoms and Progress. — Purpura is sometimes ushered in with 
vague premonitory symptoms, such as lassitude, loss of appetite, head- 
ache, and aching in the limbs, lasting from one to perhaps three or 
four weeks. In many cases, on the other hand,- the characteristic 
lesions manifest themselves suddenly in the midst of apparently per- 



564 



DISEASES OF THE VASCULAR SYSTEM. 



fectly good health. The skin becomes more or less thickly studded 
with circular, deep red, almost black spots, varying from about a 
quarter of an inch in diameter downwards, which are unattended with 
any abnormal sensation, are not elevated above the level of the skin, 
and do not fade on pressure. They are usually most abundant on the 
lower part of the trunk, and on the lower extremities, but are by no 
means confined to these situations, and not unfrequently extravasations 
take place into the eyelids, beneath the conjunctivae, and beneath the 
mucous surface of the tongue, lips, gums, and other parts within the 
cavity of the mouth. These spots go through the ordinary changes of 
color which characterize bruises, and thus fading away, usually disap- 
pear completely in the course of a few days. Successive crops of pete- 
chias, however, commonly appear from time to time, and thus the dis- 
ease may be continued for two, three, or four weeks, sometimes for a 
still longer period. Larger extravasations — vibices and ecchymoses — 
are usually associated in a greater or less degree with the eruption above 
described. But these are generally deeper seated, present less abrupt 
margins, are attended with more or less swelling, and not unfrequently 
first reveal their existence, as deep-seated bruises do, by the gradual 
diffusion and coming to the surface of their more or less modified color- 
ing matter. They are not unfrequently the result of mechanical vio- 
lence. There is always a tendency in these cases, more pronounced in 
proportion to their severity, for haemorrhages to take place from the 
mucous surfaces. In some there is more or less severe epistaxis ; in 
some, bleeding from the gums or other parts within the mouth ; in 
some, haemoptysis; in some, bleeding from the stomach or bowels; in 
some, from the kidney, or other parts of the urinary tract ; in some, 
from the uterus or vagina. In many cases this bleeding is small in 
quantity, and of little importance; occasionally, however, it is profuse, 
and frequently repeated. 

When the affection is slight, the patient may seem during its con- 
tinuance to be in good health ; more frequently, perhaps, he suffers 
from a continuance of such symptoms as may have ushered in the 
attack; sometimes the progress of the case is attended with febrile 
symptoms of a remittent type; but when profuse hemorrhages take 
place, the symptoms due to loss of blood become developed. Not only 
does the patient then become excessively pallid, but his pulse increases 
in frequency and becomes more or less jerking; he has noises in his 
ears, dilated pupils, indistinctness of vision, with muscaeand headache; 
he yawns, becomes uneasy and restless, and sometimes falls into de- 
lirium, mania, or convulsions. Death is usually due to asthenia or 
syncope. His temperature is sometimes lowered, sometimes, on the 
other hand, considerably elevated. The milder form of purpura is 
sometimes termed P. simplex ; the more severe, P. hemorrhagica. 

Morbid anatomy throws little light on this disease. Haemorrhages 
similar to those beneath the skin are sometimes discovered in the sub- 
serous and submucous tissues, and less frequently in the parenchyma of 
various organs, more especially the lungs, heart, and kidneys. Extreme 
fatty degeneration of the muscular fibres of the heart has been de- 
tected in cases fatal from repeated haemorrhage after long continuance 



SCURVY. 



565 



of the disease. The blood seems to j)resent no constant departure from 
the normal condition. It is curious, however, that Dr. Parkes has, in 
two cases which he has examined, detected in this fluid an excess of 
iron together with a general diminution of the solid constituents. It 
seems more probable, however, that the primary morbid condition is in 
the capillary and other small vessels than in the blood, and that this 
latter escapes into the tissues in consequence of their rupture. 

Treatment. — The principles of treatment of purpura are as little 
understood as its pathology. The majority of the patients get well in 
the course of a week or two without treatment. The severer cases are 
unfortunately apt to go on from bad to worse, whatever treatment be 
adopted. A certain prima facie resemblance which purpura presents 
to scurvy has induced a common belief that antiscorbutic remedies — 
fresh vegetables, citric acid, and potash — are indicated here also. 
Experience does not, however, confirm the truth of this opinion. 
Among the remedies which have been chiefly recommended are per- 
chloride of iron, acetate of lead, arsenic, digitalis, turpentine, and gallic 
and sulphuric acids. If the discharge of blood be profuse, one or other 
of these drugs may be prescribed ; and at the same time the patient 
should be kept quiet and cool, and should have ice or ice-cold drinks 
given to him. Haemorrhages taking place from accessible parts may, 
of course, be treated by local measures. If asthenia be extreme, it may 
be absolutely necessary to give alcoholic stimulants. On the whole, 
tonic treatment is indicated in those persons who have a tendency to 
purpura and in those who are convalescent from it. 



SCURVY. (Seorbutis.) 

Definition. — Scurvy may be regarded as a peculiar form of anaemia 
arising from deficiency of vegetable diet, and attended with a tendency 
to the occurrence of haemorrhages, and with profound impairment of 
nutrition, and great mental and bodily prostration. 

Causation. — This disease formerly occurred largely among sailors 
during long voyages. It has often broken out in armies on active 
service and among populations suffering from famine. It still occurs 
from time to time under these various conditions, and is occasionally 
met with as a sporadic affection among persons who are ill-fed or whose 
diet has been, from some cause or other, too exclusively animal. It is 
needless to go into a history of scurvy, or to discuss the various 
hypotheses which have been propounded in reference to its causation. 
It will be sufficient to state that its origin has been clearly traced to 
insufficiency or total want of fresh vegetables; but among these must 
not be included corn and the other graminaceae, or peas. It is still 
however, uncertain to what constituent or constituents, common to 
vegetables, their virtue is due. Dr. Garrod believes it to reside in the 
salts of potash; others, however, maintain that it dwells in the citric 
and other vegetable acids which they so often contain. There are ob- 



566 



DISEASES OP THE VASCULAR SYSTEM. 



jections, however, to both of these views, for the antiscorbutic powers of 
vegetables do not appear to be proportionate to the potash salts they 
contain, and potash salts alone are probably inefficacious ; and potatoes, 
which are powerfully antiscorbutic, are devoid, or nearly so, of vege- 
table acids. The constant use of salt meat, and long-continued expo- 
sure to privation and other such causes of ill-health, can only be 
regarded as indirectly favoring the production of scurvy. 

Symptoms and Progress. — The early symptoms of scurvy may be 
easily misunderstood when presented by sporadic cases; they cannot, 
however, fail to attract attention when they arise simultaneously or in 
rapid succession among a number of persons equally exposed to the 
conditions which are liable to give origin to the disease. They are 
rapidly progressive anaemia, indicated by a dirty-looking, pallid, 
sallow, or earthy aspect; growing indisposition for bodily exertion; 
pains of a rheumatic character in the back and limbs ; and more or 
less mental apathy or depression ; the tongue probably continuing 
clean, though becoming large, flabby, and indented by the teeth, the 
appetite remaining good, and the bowels being constipated. But soon 
other phenomena arise ; petechial spots appear, first on the lower ex- 
tremities, and then on other parts of the surface; to these large subcu- 
taneous extravasations presently succeed ; and to these, sooner or later, 
puffy swellings in different parts of the body, which seem to be due to 
deeper-seated and more copious haemorrhages, and the nature of which 
becomes revealed ere long by the occurrence of bruise-like discoloration 
of the tissues which are superficial to them. These puffy swellings 
mainly affect the popliteal spaces, the corresponding parts of the 
elbows, the anterior aspects of the lower part of each leg, and the 
regions behind the angles of the jaw, interfering with the movements 
of these parts, and causing more or less pain and tenderness in them. 
Similar extravasations are peculiarly apt to take place into the loose 
connective tissue in and about the eyelids, leading to considerable 
puffiness and bruise-like discoloration of these parts, and to sanguine- 
ous accumulation in the ocular subconjunctival tissue. Concurrently 
with the appearance of these extravasations the gums begin to swell at 
their edges ; and they rapidly increase in bulk until they form lobu- 
lated masses, which rise up around the teeth, and sometimes hide them 
altogether from view. These masses are spongy, deep red or livid, 
insensitive but apt to bleed, readily ulcerate or slough, and impart 
therefore a very fetid odor to the breath. The teeth become loose and 
frequently drop out. The same tendency to ulcerate or slough is mani- 
fested in a greater or less degree by all parts of the cutaneous surface, 
but especially by those which are the seats of the puffy swellings above 
adverted to, and by those which present the cicatrices of former in- 
juries. The slightest scratch, or pressure, or blow is often sufficient to 
induce these destructive processes. Along with these phenomena the 
patient's anaemia increases ; his face gets puffy ; more or less anasarca 
takes place in his lower extremities ; lie becomes breathless ; his heart 
acts rapidly and feebly ; and even though retaining, as he probably 
does, a good deal of muscular strength, he is liable on the slightest 
exertion, even the exertion of rising in bed, to attacks of sudden syn- 



SCURVY. 



567 



cope, which are attended with the utmost danger to life. During the 
latter periods of the disease the appetite often fails; the patient suffers 
from looseness of bowels, the motions being frequently highly offensive, 
and containing more or less blood ; he has disturbance of vision (hern- 
era] opia, nyctalopia), singing in the ears, vertigo, want of sleep, and 
occasionally delirium. His intellect remains, however, for the most 
part unaffected. In many cases during the progress of the disease 
thoracic complications arise, especially effusion into the pleura?, con- 
gestion of the lungs with extravasation of blood into their tissue, con- 
gestion of the bronchial tubes, cough, and sanguinolent expectoration, 
not unfrequently attended with a marked gangrenous odor. The dura- 
tion of scurvy may (according to circumstances) extend over many 
weeks or even many months ; and death may result either from sudden 
syncope or from gradual asthenia, which may at any time be hastened 
by the occurrence of haemorrhage, ulceration, thoracic affections, or 
other complications. 

Morbid Anatomy. — The morbid anatomy of scurvy accords with the 
symptoms of the disease ; there is tendency to rapid decomposition ; 
extravasations of blood in various stages of transformation may be 
found, not only in the superficial regions already specified, but in the 
substance of the lungs, beneath the pleura?, in the walls of the heart, 
in the subpericardial tissue, in the intestinal parietes, and beneath the 
peritoneal membrane. Sanguinolent serum also may be found in the 
various serous cavities. In other respects the condition of the viscera 
is very variable. The lungs, liver, and spleen may or may not be 
congested ; the heart may be contracted and empty, or distended with 
black blood. The brain generally is healthy. The blood contains an 
excess of fibrin, but presents a diminution in the number of the red. 
corpuscles, and an abnormally low specific gravity. 

Treatment. — The only effectual treatment of scurvy is the restoration 
to the dietary of those articles of food to the want of which the disease 
has been traced, namely, vegetables, and especially those, or those 
substances extracted from them, which contain citric acid and potash. 
Among the ordinary articles of diet which are efficacious in this respect 
must be enumerated potatoes, yams, onions, carrots, turnips, green 
vegetables of all kinds, inclusive of mustard and cress, and the scurvy 
grass; lemons, oranges, limes, grapes, and apples; and, among their 
derivatives, lemon and lime-juice and sauerkraut. The provision en- 
forced in emigrant ships, and which has been found effectual in pre- 
venting the occurrence of scurvy, is, that each person must have weekly 
at least eight ounces of preserved potatoes, and three ounces of other 
preserved vegetables (carrots, onions, turnips, celery, or mint), besides 
pickles, and three ounces of lime-juice. And among the suggestions 
issued by the Board of Trade to shipowners is the following, namely, 
that each man should have at least two ounces of lime or lemon juice 
twice a week, to be increased to an ounce daily if any symptoms of 
scurvy manifest themselves. The importance of additionally supply- 
ing scorbutic patients with good nourishing diet, of taking precautions 
against sudden syncope, and of relieving by local applications the 



568 



DISEASES OF THE VASCULAR SYSTEM. 



bleeding, ulcerated gums, and ulcers which may exist in other parts, 
is of course obvious. 



CHRONIC ALCOHOLIC POISONING. (Alcoholism.) 
DELIRIUM TREMENS. 

Persons who are in the habit of drinking freely fall after awhile into 
ill health. They lose their appetite, suffer from nausea and sickness, 
have a furred tongue and offensive breath ; the limbs become tremu- 
lous and enfeebled, the face dull and expressionless, the conjunctiva? 
congested and watery ; an eruption of acne rosacea or acne tuberculatum 
not uncommonly appears upon the nose and cheeks ; they cannot sleep, 
become low-spirited and vacillating, and lose in some degree both 
memory and readiness or quickness of apprehension. They are apt to 
become, also, cowardly, cunning, and untruthful. Further results of 
drink are, cirrhosis of the liver, which may be followed by ascites, 
jaundice, or hgematemesis ; affections of the nervous centres, including 
delirium tremens, epilepsy, mania, dementia, and general paralysis ; 
and probably also gout and its various consequences. Drinkers 
(especially, it is said, those who take beer) very often grow exceedingly 
fat ; on the other hand they not unfrequently become much emaciated. 
Innumerable material lesions and functional disturbances are, and 
have been, attributed to the abuse of alcohol; but there is no doubt 
that, in a very large proportion of cases, the mistake is made of attrib- 
uting every ailment from which a drinker suffers to the influence of 
his drink, forgetful of the fact that habits of intemperance, long con- 
tinued, expose their subject to many dangers, to be attacked by many 
diseases, from which he would otherwise probably have escaped. 

The parts which principally suffer are the alimentary canal, the 
liver, and the nervous centres ; but it is to the affections of the last- 
named organs only that we now propose to direct attention. 

Delirium Tremens. 

Causation. — Of affections of the nervous centres the most frequent, 
and on that account, if on no other, the most important, is that com- 
monly known by the name of " delirium tremens." That delirium 
tremens, or as it is sometimes called delirium e jjotu, is a direct conse- 
quence of the abuse of alcohol is beyond dispute. But different views 
have been held in respect of the mode in which alcohol influences its 
production. It was long believed that it occurred only in persons who, 
after drinking heavily, were suddenly deprived of their accustomed 
stimulus. More recent inquiries, however, show that it is the imme- 
diate consequence of excessive drinking, and that it usually comes on 
in the course of long-continued intemperance or of those occasional 
outbreaks of intemperance (lasting it may be for a few weeks at a time), 
to which some persons are liable. It may no doubt supervene at the 
time when such persons are commencing to abstain ; but not in conse- 
quence of their abstinence. 



ALCOHOLISM 



— DELIRIUM TREMENS. 



569 



[It is difficult, nevertheless, to explain the occurrence of delirium 
tremens in many cases on any other supposition than that the attack 
has been brought about by the abrupt withdrawal of stimulus. These 
attacks occur in patients, who are addicted to the excessive use of 
alcohol, shortly after admission into a hospital for injuries of so slight a 
character that it would be unreasonable to attribute any active share in 
their production to shock. Moreover, they may often be averted by 
the administration of stimulus in moderate quantities.] 

Symptoms. — The symptoms of delirium tremens creep on gradually. 
The patient loses his appetite, becomes restless and wakeful at night, 
his sleep being disturbed by frightful dreams; he grows suspicious, 
inclined to quarrel, agitated, restless, disposed to busy himself about 
various matters, and often (as Trousseau observes) to pack up his 
clothes and prepare for a journey. Generally by the time his disease 
has become fully manifested he has had no rest whatever for many 
nights, and has taken little or no solid food for many days. 

The symptoms of the declared affection comprise delirium with 
hallucinations, and tremulousness of the muscles, together with va- 
rious more or less characteristic disturbances of the other corporeal 
functions. 

The face is either congested or pale ; the pupils are usually dilated, 
the conjunctivae injected, the skin bathed in more or less profuse 
perspiration. The tongue varies in character, but in most cases is 
covered with a thick creamy fur. There is more or less thirst, but the 
appetite is in complete abeyance. Muscular tremors are almost invari- 
ably present ; they may be general, or limited mainly to certain parts, 
such as the head and neck and upper extremities ; they manifest them- 
selves especially when the patient exercises his muscles, but are not 
necessarily absent at other times ; thus, the arms tremble when he 
attempts to hold them out, the legs tremble when he stands, the 
lips tremble when they are put into motion^ and the tongue when it is 
protruded. But, besides the ordinary tremblings, there are often con- 
stant fibrillar movements of the muscles which scarcely reveal them- 
selves by causing obvious movement, but may be distinctly felt when 
the patient's limbs are grasped ; and there are often also (but more 
especially towards the later stage of the disease) involuntary startings 
of the limbs. The pulse varies. In most cases it does not, in the 
beginning, exceed the normal ; and it is then probably large, soft, and 
dicrotous. At a later period, however, and especially if the disease 
has taken an unfavorable turn, it increases in rapidity, rising it may 
be to 120 or 140, or more, and becomes at the same time small and ex- 
tremely feeble. The temperature in the majority of cases does not 
exceed 101°, and often never rises to that height; but occasionally it 
runs up more or less rapidly to 105°, or even 108° or 109°. There is 
no relation between the frequency of the pulse and the elevation of the 
temperature. The mental phenomena are peculiar. The patient's 
sleeplessness and tendency to dream soon become attended with hallu- 
cinations ; he hears noises ; he sees black spots, or sparks, or figures ; 
he perceives flavors, or smells smells ; all of which have only a sub- 
jective existence. His mind begins to wander ; he looks suspicious or 



570 



DISEASES OF THE VASCULAR SYSTEM. 



frightened ; he searches behind the bed-curtains, or under the bed, or 
in corners, to satisfy himself that there is nothing there ; he becomes 
garrulous — talking for the most part of business and of projects which 
he has in hand, but interrupts himself from time to time under the 
influence of some passing dread, or suspicion, or angry feeling. At 
this time he can be readily recalled to himself, and will answer ques- 
tions rationally and coherently. The incoherence and delirium, how- 
ever, soon increase upon him. He now probably is incessantly chat- 
tering, talking more or less incoherently of things absent and present, 
but still with a marked tendency, as a rule, to dwell upon matters of 
business, to give orders to his servants or workpeople, to talk with 
customers ; he suffers, also, from manifest illusions ; he not only has 
singing and other noises in his ears, but he hears voices, and it may be 
enters into conversation with them ; he not only sees muscse, but he 
takes them (according to their characters) to be insects, or sparks, or 
coins, and he may be seen consequently endeavoring either to catch the 
animals which infest him, or to pick up the silver which is strewed 
around him ; or he fancies that he sees larger objects, dogs or cats, 
strange persons or devils, and watches them as they slip behind some 
article of furniture, or peep at him from some obscure corner. In 
many cases his illusions are wholly of a nature to inspire horror or 
terror; policemen are after him for some murder he has committed; 
he is haunted by bad spirits; foul reptiles are crawling about him; 
great disasters threaten or have already involved his dearest friends. 
In some cases they are pleasing or funny; he is surrounded by beauti- 
ful scenery, he hears sweet music, he sees dancing girls or acrobats per- 
forming the most extraordinary feats. In some cases again he becomes 
wildly maniacal; in some sullen, morose, and stupid. He is apt also 
to mistake those about him for persons who are absent, or to confound 
them with the grotesque or horrible creations of his mind. *His actions 
are no doubt in relation with the thoughts or fancies which are passing 
through his mind; he will often, as above pointed out, be seen busily 
picking up insects, flowers, or coins which are crawling or falling about 
him ; or he will sit up and look suspiciously around ; or he will en- 
deavor to rise from his bed and will hunt everywhere for imaginary 
objects ; or he will strive to avoid some danger or some foe, or will 
attack his attendant in the belief that he is contemplating or perpe- 
trating some injury against him or his friends ; or he will perform 
various grotesque acts, such as climbing up the bed-post, or standing on 
his head, or turning head over heels, or will applaud by shouts or by 
laughter some imaginary performance. But in all cases, even though 
he has well-marked dominant illusions or frames of mind, there is a 
remarkable changeableness in his illusions and moods ; he passes mo- 
mentarily from one thing to another, and is suspicious, cowardly, vio- 
lent, and merry in rapid succession ; and in all cases, or nearly all, he 
can be recalled momentarily to himself, and can be restrained by the 
voice of authority. Epileptiform attacks occasionally come on in the 
course of delirium tremens. 

In the majority of cases, delirium tremens terminates favorably ; and 
at the end of three or four days, or it may be a week, from the com- 



ALCOHOLISM — DELIRIUM TREMENS. 



571 



mencement of his malady, the patient falls into a gentle sleep and 
awakes refreshed and convalescent. But occasional ly (and in those 
persons whose habits insure frequent recurrence, necessarily at length) 
the attack ends fatally by coma or asthenia. The circumstances which, 
according to M. Magnan, foretell a fatal issue are elevation of tempera- 
ture, persistent muscular agitation, and muscular debility or paresis. 
If the temperature rises to 102° or 103° (even though other symptoms 
appear favorable) there is ground for alarm ; if, after continuing at 
this elevation for a day or two, it suddenly rises above 104°, the dan- 
ger becomes very great, and in some degree proportionate to the 
amount of the rise. As regards muscular tremors, it is not so much 
their intensity as it is their general prevalence and their persistence 
which should excite alarm. They are especially of ill omen when 
they continue during sleep, and when to the general muscular vibra- 
tion is superadded subsultus tendinum. Great rapidity and extreme 
feebleness of pulse, epileptic convulsions, coma, and the formation of 
bed-sores point also to a fatal termination. 

The subject of delirium tremens must not be dismissed without 
drawing attention to the fact that in persons who are habitual drinkers, 
it not unfrequently happens that other illnesses (acute or chronic) 
which attack them become complicated with some of the symptoms of 
delirium tremens. Thus it is with serious accidents, pneumonia, and 
other inflammatory and febrile disorders, and thus, also, it not uncom- 
monly is with hysteria. Nor must it it be forgotten that delirium 
tremens is apt to be closely simulated by various affections, and more 
especially by meningitis and acute inflammations of various organs. 

Other consequences of drink are epilepsy, insanity in its various 
forms, general paralysis, and dementia. These, however, are not special 
to alcoholism, and need not now detain us. 

Pathology and Morbid Anatomy. — Alcohol taken into the stomach is 
very rapidly absorbed. It is eliminated, but apparently in very minute 
quantity, by the kindeys, lungs, and skin; yet it disappears quickly 
from the system. Generally, even if large quantities have been im- 
bibed, none can be detected by chemical analysis after the third or 
fourth day ; but Dr. Dupre believes that ten days may be taken as 
the period needed for its entire discharge. It is obvious, therefore, that 
the great bulk must undergo chemical decomposition in the interior of 
the body. Alcohol may be found post mortem in various organs ; it 
has been discovered in the liver, but is much more readily detected in 
the brain, for which organ it seems to have a special affinity. The con- 
ditions of the stomach, intestines, and liver which supervene upon 
chronic alcoholic poisoning are elsewhere described. The post-mortem 
appearances presented by the central nervous organs are not very strik- 
ing; in those who have been long given to drink, the brain is often 
found to be somewhat shrunken, the subarachnoid tissue opaque, and 
its proper fluid in excess ; but in those who die of delirium tre- 
mens, there is usually more or less marked congestion of both the 
cortex and medulla of the brain and of the upper part of the spinal 
cord. Moreover, there is not unfrequently discovered a deposit of re- 
fractive granules in the walls of the small vessels, and even of hse- 



572 



DISEASES OF THE VASCULAR SYSTEM. 



matoidin crystals. There is no reason to believe that other tissues or 
organs suffer in any important degree. Dr. Dickinson has clearly 
shown that there are no sufficient grounds for referring chronic renal 
disease to the effects of alcohol. 

Treatment. — Our remarks under this head will have reference solely 
to delirium tremens. It is impossible to reconcile the different views 
that are held with respect to the treatment of this disorder. Formerly 
it was held, and by physicians of high eminence and of large practical 
experience, that the one thing needful was to give the patient sleep. 
But now Drs. Laycock, Gairdner, Wilks, Anstie, and many others 
urge that the disease is one of low mortality, which tends to get well 
of itself within a limited time, and that not only is opium not needed, 
but that its use is attended with no inconsiderable danger. The patient 
has been without food, or almost without food, for a considerable length 
of time ; and they strongly urge that he should be fed with such nour- 
ishment as he can be made to take, and that it is by nourishment mainly 
that he is to be successfuly treated. We do not deny that many of these 
cases do tend to recovery, and that feeding is an essential point in their 
treatment; but we cannot help thinking that more power for harm, and 
less power for good, than it deserves, have been latterly attributed to 
opium. We think, too, that opiates may be given with more benefit 
and less danger in inflammatory and other lesions of the brain than is 
generally suspected. A person suffering from delirium tremens should 
be separated from other patients ; the room in which he is placed should 
be kept absolutely quiet, and the bright light of day should be ex- 
cluded. Everything, indeed, around him should tend to quietude and 
to solicit sleep. He should be constantly watched by a trustworthy 
and competent attendant. Under these circumstances it is not generally 
requisite to employ mechanical restraint; yet sometimes it becomes ab- 
solutely necessary to tie him down with a sheet or band, or to fasten 
his hands and feet to the bed with gauntlets. Nutriment should be ad- 
ministered with careful attention in small quantities and frequently. 
The most appropriate articles of food are milk, arrowroot, beef tea, 
broths, and eggs. The bowels should be regulated. Those who con- 
sider sleep indispensable would now administer either chloral or some 
preparation of opium. The chloral is sometimes given with advantage 
in doses of from ten to twenty grains every half-hour until sleep is in- 
duced. Opium or morphia may also be given in comparatively small 
doses at short intervals. It is better, however, we believe, to admin- 
ister it from the beginning in large doses, and to repeat it or not ac- 
cording to its effect ; to give, for example, from half a grain to a grain 
of morphia, or from half a drachm to a drachm of laudanum at once, 
and to repeat the medicine in smaller doses at intervals of an hour or 
two, if sleep be not induced. So also w T ith respect to chloral, we be- 
lieve it better to give a large dose at once, say sixty or eighty grains, 
and to supplement this with subsequent smaller doses, if needful. If, 
as is doubtless best, the morphia be given by subcutaneous injection, the 
dose must be reduced to one-sixth or one-third of a grain. It may be 
well to add that patients with delirium tremens are difficult to bring 
under the influence of narcotics. Other remedies which have had, or 



CHRONIC LEAD -POISONING. 



573 



have, strong advocates, are : digitalis in large doses (half an ounce to 
an ounce of the tincture); cayenne pepper; and bromide of potassium 
in doses of from ten to thirty grains. It is sometimes advisable to give 
the patient some of the alcoholic stimulus to which he has been addicted. 
When he is convalescent, quinine or other tonics are indicated, and he 
should, as far as possible, be debarred from drink. The probability, 
however, is that he will, so soon as opportunity offers, resume his evil 
habits. 



CHRONIC LEAD-POISONING. (Plumbism.) COLIC. 
DROPPED HAND. 

Causation. — When lead, in even minute quantities, is habitually intro- 
duced into the system, characteristic and more or less serious consequences 
are pretty certain to ensue, sooner or later. In most such cases the poi- 
soning is very insidious, and not unfrequently its source is only dis- 
covered after patient research or by accident. Plumbism was formerly 
largely prevalent in Poictou, in consequence of the habitual addition 
of lead to inferior qualities of wine; in the West Indies, owing to the 
fact that leaden worms were used in the stills employed in the manu- 
facture of rum ; in Devonshire, as a result of the general employment 
of lead in the construction of the vessels used in making cider ; and 
both in our own country and elsewhere, as a consequence of the storage 
of drinking water in leaden cisterns, or its conveyance through leaden 
pipes. In all these cases the fluid, acting chemically upon the lead, 
and rendering it soluble, became in a greater or less degree impreg- 
nated with it. It is worth while to draw attention to the fact that 
rain water and other soft waters become much more readily impreg- 
nated with lead than hard waters, provided these latter contain sulphate 
and carbonate of lime, and not too large a proportion of alkaline chlo- 
rides or nitrates. At the present day the contamination of drinking 
water with lead is comparatively rare ; and the chief source of lead- 
poisoning is the employment of this metal in manufacture and trade. 
To quote the words of Dr. Taylor, " The carbonate " (to which salt 
chronic poisoning is usually attributable) " finds its way into the sys- 
tem, among white-lead manufacturers, either through the skin or 
through the lungs, or both together ; it is diffused through the air as 
a fine dust, and is not only respired, but taken into the mouth and 
swallowed with the saliva. It has been remarked that in factories 
where the powder was ground in a dry state, not only have the la- 
borers suffered, but horses, dogs, and even rats have died from its 
effects. Since the practice has arisen of grinding the white-lead in 
water, cases of colica pictonum have not been so numerous. They are 
still, however, not unfrequent among painters, plumbers, pewterers, the 
manufacturers of some kinds of glazed cards, the bleachers of Brussels 
lace, and among those engaged in the glazing of pottery, where oxide 
of lead is employed in the glaze." "The workers in metals — plumb- 
ers who handle metallic lead — are but little subject to the disease." 



574 



DISEASES OF THE VASCULAR SYSTEM. 



Amongst rare but well -ascertained causes of lead-poisoning are the 
employment of lead medicinally, its application to ulcerated surfaces 
(Althaus), the use of snuff impregnated with lead (Hassall and Garrod), 
and sleeping in a newly-painted room. [The application of lead, either 
alone or diluted with an inert powder, to the face and neck as a cos- 
metic, even when the skin is entirely unbroken, has also been followed 
by well-marked symptoms of poisoning.] Some persons present the 
symptoms of plumbism who have been exposed in a very slight degree 
to the poison, who have taken, it may be, only a dose or two of lead 
medicinally; while others (painters, for example) may go on with their 
work for twenty years or more, and yet escape. 

Symptoms and Progress. — Those who are under the influence of the 
chronic operation of lead often suffer more or less in their general 
health ; their complexion is said to get sallow and earthy-looking, 
their skin dry and harsh ; they become thirsty, lose appetite, and have 
a sweetish or metallic taste in the mouth. Dr. Garrod points out a 
remarkable connection between gout and plumbism, shown by the cir- 
cumstance that a very large proportion (one-fourth) of his hospital 
gouty patients have suffered from lead-poisoning. And, indeed, 
whether that connection be accidental, or due to the fact that lead- 
poisoning predisposes to gout, or to the fact that constitutions liable to 
gout are also peculiarly susceptible of the influence of lead, general 
experience seems to confirm the accuracy of Dr. Garrod's observation. 
Chronic albuminuria is also not unfrequently associated with lead- 
poisoning. A curious effect of lead was discovered some years ago by 
Dr. Burton, which is of great importance from a diagnostic point of 
view: it is the formation of a blue line along the edges of the gums 
immediately adjoining the teeth. This is situated in the substance of 
the gum, but appears to be largely determined by the amount of tartar 
present, and is supposed to be due to the precipitation of the lead, in 
the form of the sulphide, by the sulphuretted hydrogen emitted by the 
decomposing matters which are mingled with the tartar. This blue 
line is not, however, an infallible sign of lead-poisoning, for it occa- 
sionally becomes developed in the course of a few hours after the use 
of two or three medicinal doses of lead ; it is generally present in 
lead-workers who are free from all other symptoms ; it often remains 
long after all possibility of poisoning has passed away ; it is sometimes 
absent from cases of undoubted plumbism ; and, further, it may be 
caused by cuprous and other varieties of metallic impregnation. It is 
said that a similar blue line may be detected at the verge of the anus, 
and at the margins of ulcers. By far the most important consequences 
of lead-poisoning, however, are colic, and certain affections (mainly 
paralytic) of the nervous system. Of these, colic is the more common, 
and, when the two conditions coexist or alternate, is usually the earlier 
in making its appearance. 

1. Lead colic is characterized by the more or less gradual superven- 
tion of severe griping pains, attended with obstinate constipation and 
often with vomiting. The pains differ in no respect from those which 
follow upon impermeable intestinal stricture, and apparently are due 
to the same cause, namely, the powerful contraction, frequently re- 



CHRONIC LEAD-POISONING. 



575 



peated, of certain lengths of bowel above, in order to overcome some 
impediment to the passage of their contents into and through the 
length of bowel immediately following. They are referred mainly, as 
such pains usually are, to the umbilical region, come on at intervals 
with extreme severity, and, when the disease is fully established, are 
associated with more or less intense interparoxysmal uneasiness or pain. 
The pain is not generally aggravated by pressure, and indeed is often 
relieved both by that means and by friction. The paroxysms are at- 
tended with more or less obvious peristaltic movement of the bowels, 
and with borborygmi. Vomiting may arise early from sympathy or 
late from the direct influence of obstruction. The abdominal walls are 
usually retracted, and the muscles hard and tense. Colic very rarely 
proves fatal ; but might readily become fatal if the cause to which it is 
referable should continue in operation. Its duration varies; it may 
last for a day or two only, or be continued for a week, or, with remis- 
sions, for a still longer period. Moreover, when once there has been 
an attack there is great liability to recurrence. It is rarely if ever at- 
tended with fever or with intestinal inflammation. 

2. Nervous Disorders. — Dropped Hand. — Of nervous disorders, 
dropped hand, from paralysis of the extensors of the forearm, is by far 
the most frequent ; but sometimes the paralysis is of much more general 
diffusion. Dropped hand generally comes on consecutively to colic, 
sometimes gradually, sometimes more or le*s suddenly. In some cases 
one hand only is affected, and this is usually the right ; but more fre- 
quently both hands are implicated, though in unequal degrees. The 
more obvious symptoms of the affection are loss of power over the 
extensor muscles of the forearm, in consequence of which the patient 
becomes unable to extend his hand upon the arm, or to extend the first 
phalanges of his fingers upon the metacarpal bones, to adduct or abduct 
the hand, or to abduct the thumb. The hand consequently drops when 
the arm is held out prone, and both the hand and fingers are more or 
less powerfully flexed in consequence of the predominant action of the 
flexor muscles. The paralyzed muscles waste rapidly, so that a distinct 
hollow is apt ere long to manifest itself between the bones at the back 
of the forearm ; and moreover, while retaining their electro-sensibility, 
they lose more or less completely their electro-contractility. The 
remaining muscles of the forearm, and even those of the upper arm, 
are apt to be enfeebled, though not otherwise affected. There is no im- 
pairment of cutaneous sensibility ; although it not unfrequently happens 
that more or less severe pain and tenderness in the situation of the 
affected muscles attend the acute stage of the affection. 

It is an important fact that the paralysis is limited, as a rule, to 
muscles supplied by the radial nerve. Those which mainly suffer are 
the following, enumerated in the order in which (according to Du- 
chenne) they are liable to be attacked : the extensor communis digit- 
orum, the extensor indicis, the extensor minimi digiti, the extensor 
secundi internodii pollicis, the extensor carpi radialis brevior, the ex- 
tensor carpi radialis longior, the extensor carpi ulnaris, the extensor 
ossis metacarpi pollicis, and the extensor primi internodii pollicis. 
Occasionally also the muscles of the ball of the thumb suffer. But the 



576 DISEASES OF THE VASCULAR SYSTEM. 



supinators, the muscles of the front of the forearm, and those of the 
hand (with the exceptions which have been pointed out), although they 
may get enfeebled, seem never to become distinctly paralyzed, or to 
lose their electric contractility, or to waste. It must be borne in mind, 
however, that the muscles are not necessarily involved in the order 
above named, and that they do not necessarily all suffer in every case. 
If the extensor communis be alone affected, the middle and ring fingers 
alone drop, the index and little finger retaining the power of extension, 
though somewhat enfeebled; if the extensores indicis and minimi digiti 
also suffer, al] four fingers are implicated. The power of supination 
and that of pronation remain intact ; and provided the first phalanges 
be supported in the extended posture, the second and third phalanges 
may always be voluntarily extended, a fact confirming the integrity of 
the interossei muscles. 

In some instances the paralysis, loss of electro-contractility, and 
wasting involve other muscles of the upper extremity besides those of 
the forearm. Those which are then chiefly liable to suffer are the del- 
toid and triceps. In some cases the paralysis is limited to the deltoid. 
Occasionally, again, lead-palsy involves the muscles of lower extremi- 
ties, selecting especially the extensors of the foot upon the leg, and of 
the leg upon the thigh ; or the intercostal muscles ; or the diaphragm. 
And in some very rare cases, of which Duchenne quotes a striking 
example, paralysis attacks with more or less suddenness nearly all the 
voluntary muscles. 

The duration of saturnine paralysis is very various ; it may be weeks, 
months, or years. Moreover, the paralysis, like the colic, is always apt 
to recur. The longer it has been in existence, the less, as a rule, is the 
prospect of ultimate recovery; and further, extreme wasting of the 
muscles, and persistent failure of electric contractility, are also of bad 
augury. Yet Duchenne draws attention to the interesting fact that in 
these cases voluntary power may occasionally be recovered, even though 
the muscles remain irresponsive to electrical excitation. 

Epileptic attacks sometimes come on in the course of lead-poisoning ; 
and other cerebral phenomena, including coma. 

Pathology and Morbid Anatomy. — After lead has been received into 
the organism, it becomes deposited in various parts, and discharged by 
various emunctories. It has been found post mortem in the spleen, 
liver, lungs, kidneys, heart and intestinal walls, and also in the sub- 
stance of the brain and in the muscles. It passes off mainly with the 
urine; but, according to Dr. Pereira and others, there is some elimina- 
tion by the skin ; and Dr. Taylor states that it has been found in the 
milk. It is apt to remain in the tissues for some time, and has been 
detected in them by M. L. Orfila as long as eight months after its recep- 
tion has been discontinued. The appearances found after death from 
chronic poisoning are for the most part very indecisive. After death 
from colic, or in cases in which colic has been present, the bowels 
(especially the large intestines) are said to be generally contracted and 
empty, or to present alternate contractions and dilatations, or intussus- 
ceptions ; occasionally, also, spots of congestion have been seen in the 
mucous membrane. These are changes, however, which may be ob- 



CHRONIC LEAD- POISONING. 



577 



served in many cases besides those of lead-poisoning. The paralyzed 
muscles, as has been already stated, shrink rapidly and to an extreme 
degree; and post mortem are often observed to be remarkably pale and 
yellowish. But, on microscopic examination, their tissue is usually 
found to present a perfectly normal appearance. It is only after paral- 
ysis has existed for many years that degenerative change becomes 
added to mere atrophy. The fibres then sometimes become fatty. 
Whether the intestines are affected through the nervous system, or by 
the presence of lead in their walls, may be a subject of doubt. But, as 
regards the paralysis of the voluntary muscles, there is no doubt that 
Duchenne is right in regarding it as a consequence of nervous disorder. 
For if it were muscular, not only should we find the muscular fibres 
degenerated in proportion to their loss of power, but we should find that 
electrical contractility would survive as long as any healthy muscular 
fibres were left. On the other hand, the rapid shrinking of the muscles, 
without degeneration, and their speedy loss of electrical contractility, 
obviously point to lesion, either of the nerve-trunks or of their nuclei 
of origin. 

Treatment. — Whenever a case of lead-poisoning comes under treat- 
ment a careful inquiry should be made into the probable source of con- 
tamination, with the object of removing or counteracting it, or of put- 
ting the patient upon his guard. It is obvious that it would be well 
for patients whose occupation exposes them to the danger of continued 
lead-poisoning, to seek some other employment. But this they will 
rarely consent to; and indeed, it is often quite impossible for them to 
do it. Apart from the question of the improvement of processes of 
manufacture in order to minimize the risks of those employed (a sub- 
ject upon which we do not presume to enter) it may be mentioned that 
extreme personal cleanliness is important for all those who are exposed 
to danger ; and that there are good grounds for believing that the 
habitual use of lemonade made with sulphuric acid is to a considerable 
extent protective, by converting the carbonate or other salts of lead in 
the stomach into the insoluble sulphate. 

Various methods of treatment have been suggested with the object 
of removing lead from the system — the more important of them being 
the employment of baths containing some soluble sulphide, and the 
internal use of iodide of potassium. Dr. Pereira recommended baths 
medicated by dissolving sulphide of potassium in them, in the propor- 
tion of two ounces to fifteen gallons, in the belief that the lead escap- 
ing from the surface of the skin would thereby be converted into the 
insoluble sulphide. This result does in fact happen ; but there is no 
reason whatever for suspecting that the baths promote the escape of 
lead in any important degree. M. Melsens suggested the employment 
of iodide of potassium, on the ground that the iodide makes, with the 
insoluble salts of lead deposited in the tissues, a soluble double salt 
capable of removal by the kidneys. It is exceedingly doubtful, how- 
ever, whether any real benefit follows from the use of the iodide 
of potassium. 

In the treatment of lead-colic it is best, we believe, to relieve pain 
and discomfort by opiates and fomentations, and to leave the bowels to 

37 



578 



DISEASES OF THE VASCULAR SYSTEM. 



1 



act of themselves, as they will usually do at the end of a few days. If 
it be thought right to remove the contents of the lower bowel, this may 
be effected by means of copious enemata of warm water or warm gruel. 
Many, however, prefer the course which Sir Thomas Watson advo- 
cates, namely, the exhibition of a full dose of calomel and opium : 
ten grains of the former with two of the latter, which he says usually 
soothes the vomiting, the restlessness, and the pain, and may be fol- 
lowed up successfully by a dose of neutral salts or of castor oil. Alum, 
in doses of a scruple or half a drachm three times a day, has been 
highly recommended. 

For the restoration of the paralyzed and wasting muscles, galvanism 
is the only effectual remedy. Faradization is employed by M. Du- 
chenne, who recommends that a powerful current should be used three 
times a week for as long a period as may be necessary — it may be as 
much as two or three months. Each sitting may last for ten or fifteen 
minutes. He recommends, also, that each muscle should be separately 
galvanized. The slowly interrupted constant current similarly em- 
ployed, is even more efficacious. 



CHRONIC MERCURIAL POISONING. (MercuriaUsm.) 

Causation. — Chronic mercurial poisoning may result from the long- 
continued medicinal use of any of the preparations of mercury ; but it 
is most frequently due to habitual exposure to the vapor or the dust of 
mercury, or its salts, which certain manufactures or trades involve. 
Those, therefore, w T ho chiefly suffer are the workmen engaged in quick- 
silver mines ; water-gilders ; the manufacturers of looking-glasses, 
barometers, and thermometers ; furriers and those engaged in the 
packing of furs which have been brushed over with solution of nitrate 
of mercury. 

Symptoms and Progress. — The symptoms of chronic mercurial 
poisoning have reference mainly to the nervous and muscular systems, 
and are commonly included under the term "metallic tremor." The 
first indications of this condition are a general tremulousness of the 
hands and arms,, coming on for the most part gradually, slight numb- 
ness or tingling in the hands or feet, and occasionally pains in certain 
joints, more especially those of the thumbs, elbows, feet, and knees. 
These tremors are common amongst workpeople exposed to the vapor 
of mercury, and may continue for years without materially interfering 
with their capacity for work or their general health. But sooner or 
later they tend to become aggravated; they not only become more 
violent, but they gradually extend to all parts of the muscular system ; 
so that finally they involve the hands and arms, the legs, the head and 
neck, including the muscles of expression, of speech, and of deglutition, 
and the trunk, together with the muscles of respiration. Then the 
violent trembling of the hands and arms renders the patient more or 
less incapable of using them for any purpose, especially for delicate 



CHRONIC MERCURIAL POISONING.' 



579 



operations; he probably cannot lift a glass of water to his lips, or feed 
himself, or dress himself; the agitation of his legs gives to his attempts 
to walk or stand a peculiar jerkiness or choreic character, and, indeed, 
before long he is probably unable to stand or walk without support; 
the convulsive action of the muscles of his head and neck causes con- 
stant tremulous movements of these parts, while that of the muscles of 
expression reveals itself in grimaces, and that of the lips and tongue 
and of the muscles of mastication causes tremulous, indistinct, and 
divided utterance, and difficulty of mastication. The involvement of 
the respiratory muscles induces more or less difficulty of breathing. 
All these, convulsive movements are usually in abeyance when the 
patient is lying down and making no muscular effort; but they reveal 
themselves whenever he attempts voluntary movement, and especially 
become aggravated whenever he is under observation. Further, the 
patient is liable to occasional, apparently causeless, exacerbations of 
more or less severity. At a very advanced period of the disease, the 
convulsions do not wholly cease when the patient is in bed; and occa- 
sionally then they continue also during sleep. Moreover, they are now 
not un frequently associated with sharp pains in the limbs, and occa- 
sional attacks of tonic contraction. It would seem, and the point is an 
important one, that the muscles of the eyeballs do not share in the 
convulsive movements, and that consequently there is an absence of 
nystagmus. There is no real loss of sensation. 

The symptoms above enumerated are not necessarily associated with 
any other indications of mercurial poisoning or other signs of ill-health. 
But in a considerable number of cases the patients either have previ- 
ously suffered from salivation, and ulceration of the gums, fetid breath, 
nausea, sickness, colicky pains, disturbance of the bowels, and fever; 
or present these phenomena in a more or less marked form at the time 
when the nervous symptoms supervene ; or begin to suffer from them 
during the course of the tremors, even if they have never suffered 
previously. And generally after the tremors have attained a high de- 
gree of severity, cachectic symptoms come on ; the patient becomes 
sallow, emaciated, and weak; he loses his appetite, and there is more 
or less general failure of his circulatory and other functions. Some- 
times, also, various cerebral complications become developed, such as 
vertigo, headache, loss of memory, delirium, epilepsy, paralysis, or 
coma. 

Chronic mercurialism is not generally a fatal or even dangerous dis- 
ease ; mainly, however, for the reason that those who are affected with 
it are usually compelled to give up their employment, and thus escape 
further risk. But for such as continue to expose themselves to the 
vapor of mercury, the prospect of early death is by no means uncertain 
— death under such circumstances being caused, either by extreme de- 
bility, or by some of the ordinary effects of mercury on the gums and 
mouth, or intestinal canal, or by some cerebral complication, or by the 
supervention of intercurrent disorders. 

The affections with which mercurial tremors are most likely to be 
confounded are multiple sclerosis, and paralysis agitans. But the his- 
tory and a careful attention to the details of symptoms will generally 



580 



DISEASES OF THE DIGESTIVE ORGANS. 



I 



enable an accurate differential diagnosis to be made between them. It 
may, however, be worth while to point out, as practical hints, that true 
paralysis agitans does not affect the muscles of the head and neck, but 
imparts to the patient a tendency to run forwards, and that generally 
there is in multiple sclerosis well-marked nystagmus. 

Morbid Anatomy. — No characteristic lesions have been discovered in 
the internal organs of patients who have died of chronic mercurial ism. 
But mercury has been detected chemically in various parts of the body, 
more especially the brain, liver, and kidneys. 

Treatment. — The preventive treatment of mercurial poisoning includes 
the taking of measures to guard against the entry of mercury into the 
system, either by adopting such modifications of the processes of manu- 
facture as minimize the diffusion of the poison through the atmosphere, 
or by compelling the workers to wear respirators or other protective 
coverings to the face, to wash their hands before eating, and to change 
their clothes and to wash after leaving work. The direct treatment of 
chronic mercurialism by drugs is of little use. It may on the whole 
be judicious to act on the bowels, kidneys, and skin, for the purpose of 
promoting the discharge of the poison. It may even be well to adopt 
the treatment already suggested for chronic lead-poisoning, namely, 
the administration of iodide of potassium, with the object of making 
the mercury in the system combine therewith into a soluble double salt. 
But the essential part of the treatment, and that which is alone of real 
efficacy, is the removal of the patient from the influence of mercury. 
Excepting in cases of extreme severity o^ of long duration, restoration 
to health is thus effected in the course of a few weeks or a few months. 
Tonics may often be given with advantage to the patient's general 
health ; and galvanism may be applied with benefit to the enfeebled 
muscles. 



V— DISEASES OF THE DIGESTIVE ORGANS. 

(1.) — DISEASES OF THE MOUTH, FAUCES, AND 
ADJACENT PARTS. 

CATAKRH. 

Causation. — The most common, and on the whole perhaps the most 
important, variety of inflammation affecting the mouth, fauces, and 
parts in relation with them is that which results from exposure to cold, 
and gives rise to the phenomena which collectively constitute what is 
commonly known as a "cold " or catarrh. 

Morbid Anatomy. — Catarrhal inflammation commences w 7 ith hyper- 
emia, infiltration, and tumefaction of the affected mucous tissue, 
diminution of the secretions from the surface and from the glands 



CATARRH. 



581 



which open upon it, and consequent abnormal dryness. Before long, 
however, the congested surface begins to pour out a thin, watery, some- 
what acrid discharge, in considerable abundance, and at the same time 
the tumefaction usually undergoes some diminution. Subsequently 
the secretion becomes thick, opaque, and yellowish or greenish, and 
assumes the characters of muco-pus or pus. This change generally 
indicates the commencement of the end ; for, if the case go on quite 
favorably, the tumefaction and secretion both gradually subside, and 
the mucous membrane returns to its normal state. Catarrhal inflam- 
mation does not, as a rule, seize at once on any extensive tract, but 
rather, like erysipelas, commences in a comparatively small area, 
whence it gradually spreads. Nor does it even in the case of any one 
who is liable to it, always commence in the same spot. Thus it often, 
perhaps most frequently, begins in the mucous membrane of the nose, 
whence it spreads by continuity to the fauces and thence to the larynx 
and probably to the trachea and bronchial tubes ; or it first manifests 
itself in the larynx, whence it extends upwards into the nose, and 
downwards into the chest ; or it first attacks the fauces, or the soft 
palate, or it may be the gums. The regions which are liable to become 
involved in the course of catarrh, and in any one of which probably 
it may commence, thence extending to the others, are the following: 
the cavity of the nose and the sinuses in relation with it, together with 
the lachrymal ducts and the conjunctivae; the fauces and pharynx, 
together with the Eustachian tubes and tympanic cavities, and the 
oesophagus ; the oral cavity, including, it may be, the palate, the gums, 
the sockets of the teeth, or the tongue; the periosteum of the bones of 
the face, and the branches of the fifth pair; and, lastly, the larynx and 
subordinate respiratory passages. 

Symptoms and Progress. — The symptoms of a cold necessarily differ 
according to the regions which mainly suffer. The special symptoms, 
however, are always associated with the ordinary phenomena of febrile 
disturbance. These latter vary in their severity, but are generally 
mild and sometimes scarcely noticeable, and are always most severe 
during the first day or tw T o of the attack. They comprise elevation of 
temperature, heat and dryness of skin alternating with perspirations 
which come on mainly at night-time, increased frequency of pulse, 
thirst, constipation, scanty urine with abundant uratic deposit, some- 
times rheumatic pains, and frequent drowsiness. The febrile symptoms 
are sometimes alarming in the case of young children. 

The symptoms of catarrh affecting the cavity of the nose are in the 
first instance dryness, more or less complete obstruction and extreme 
irritability of the nasal passages, associated with frequent paroxysms 
of sneezing, the performance of respiration mainly through the open 
mouth, and inability to pronounce the nasal consonants m, n, and ng. 
To these succeeds more or less copious defluxion of thin watery mucus 
which frets the margins of the nostrils and the portion of the upper lip 
over which it runs. There is still probably great irritability of the 
mucous surface with paroxysmal sneezing ; but with the continuance 
of the discharge the nasal passages become more pervious, and the 
symptoms due to obstruction to some extent subside. Finally, the 



582 



DISEASES OF THE DIGESTIVE ORGANS. 



discharge becomes thick, and at the same time less abundant, the 
tumefaction and irritability of the mucous membrane diminish, and 
convalescence ensues. Associated with nasal catarrh there is always 
more or less complete loss of the sense of smell, especially during the 
earlier stages; and, probably owing to implication of the frontal 
sinuses, there is often severe headache, limited to the situation which 
the sinuses occupy, and not unfrequently attended with drowsiness. 
The extension of the catarrhal inflammation to the conjunctivae is 
shown partly by obstruction of the lachrymal ducts, in consequence of 
which the tears are compelled to flow over the face, partly by the de- 
velopment of actual ophthalmia. 

The indications of catarrhal inflammation of the fauces are, unnatural 
redness of the soft palate and pillars of the fauces, and, in a greater or 
less degree, of the contiguous mucous surfaces ; and tumefaction of the 
same parts, but more particularly perhaps of the lax tissue of the uvula, 
which is apt to become cedematous and enlarged in all its dimensions. 
The first symptoms of which the patient complains are dryness, stiff- 
ness, and itching, or tingling commencing at one side, or in some 
defined area, but soon becoming more or less general throughout the 
fauces and soft palate, frequent tendency to swallow in order to relieve 
the uncomfortable feeling in the throat, to clear the throat, and to 
cough a slight hacking cough. The act of deglutition is more or less 
painful. With the supervention of the stage of secretion, the efforts to 
swallow and clear the throat get more effective and less painful, the 
patient becomes comparatively comfortable, and convalescence soon 
follows. Involvement of the Eustaehinn tube and ear is indicated first 
by itching or shooting pains in the course of the tube and in the ear, 
then by deafness and the usual signs of aural inflammation. Exten- 
sion of catarrh along the oesophagus to the stomach is rarely if ever 
manifested by prominent symptoms. Those usually observable are a 
sensation of warmth along the oesophagus and in the stomach, and slight 
dyspeptic symptoms, more especially frequent eructations, and craving 
for food. 

Catarrhal inflammation of the mouth more frequently and seriously 
affects those who suffer from bad teeth than those whose teeth are 
sound, and reveals itself mainly by pain, tenderness, and swelling of 
the gums, and particularly of the periosteum of the sockets of the teeth. 
The teeth consequently become loose and tender when pressed upon, 
and neuralgic pains, often most severe at night-time, flicker about the 
gums, and sometimes extend to the periosteum of the jaws, and along 
the superficial branches of the fifth pair. 

Catarrhal inflammation of the larynx is elsewhere described under 
the name of laryngitis, and that of the bronchial tubes under the name 
of bronchitis. 

It remains to say that catarrh, in the sense in which the word is em- 
ployed in the present article, is an affection of very various importance. 
In the majority of cases it must be regarded as a trivial disorder, which 
reaches its full development in the course of a day or two, and lasts 
at the outside not more than a week or ten days. Yet it may, with- 
out attaining any special severity, be kept up for an almost indefinite 



CATARRH. 



583 



period if the patient continue to expose himself to its exciting cause. 

| Nor can it be regarded as entirely devoid of danger, especially if it 
involve the larynx or bronchial tubes, for although in many cases the 
larvngeal or bronchial affection is reallv slight, it differs in degree 

i only from the severest forms of primary laryngitis or bronchitis, and 
may readily pass into one or other of them. Further, although the 
pain and discomfort of catarrh are not commonly severe or of long 
duration, there are exceptions to both of these rules. The chief excep- 
tions are furnished by those cases in which the inflammation spreads 
to the teeth, periosteum, and branches of the fifth pair, and those in 
which it attacks the ear — in both of which cases the pain is often 
intense, and continues, maybe with little intermission, for weeks or 

I months. 

Treatment. — Trivial as a common cold may seem to be, it is yet of 
such frequent occurrence, and a source of so much discomfort, espe- 
cially to those who are liable to its attacks, that its treatment cannot 
be regarded as unimportant. As a general rule patients suffering from 
cold should confine themselves to a warm and well-ventilated, but not 
draughty room, and should, if not in bed, be warmly clad. A hot 
bath — water, vapor, or air — should be taken before going to bed, to- 
gether with some warm drink, and a little Dover's powder — measures 
which are serviceable in relieving pain and discomfort, in promoting 
sleep, and in exciting perspiration. During the day the occasional 
inhalation of steam is often very useful, as also are frequently repeated 
small doses of ipecacuanha and opium, either in the form of Dover's 
powder, or associated with some febrifuge mixture, or with ether or 
ammonia. Sir T. AVatson notices with especial approval the treatment 
of a commencing catarrh with (in the adult) about twenty minims of 
laudanum at one dose, or with about half that quantity of laudanum 
combined with seven or eight minims of vinum anthnoniale, repeated 
every three or four hours for three or four times; as also Sir Henry 
Halford's practice (which accords pretty nearly with the usual domestic 
routine) of giving at bedtime a beaker of hot wine negus with a table- 
spoonful of the syrup of poppies. He also observes that there is "a 
period in catarrh which has gone on unchecked when you may acccel- 
erate its departure by a good dinner and an extra glass or two of wine." 
Counter-irritation is sometimes serviceable, and if the fauces or larynx 
be dry and uncomfortable, the frequent sipping of warm milk, or bar- 
ley-water, or gruel, or " treacle posset," or the use of black-currant 
jelly, or such-like things, is often a source of considerable comfort. In 
the later stages of faucial catarrh, or when the affection has become 
chronic, astringent applications, either in the form of gargles or of spray 
by means of the atomizer, may be useful. Occasionally, but for the 
most part as the result of repeated catarrhal attacks, the uvula becomes 
elongated, and is believed to irritate the larynx, with which it comes 
in contact. Under such circumstances the tip may be readily and safely 
snipped off with scissors. 

It is very desirable to obviate, if possible, the liability to catarrh 
which so many persons labor under. There is no doubt that active 
exercise in the open air, and all other habits which tend to promote 



584 



DISEASES OF THE DIGESTIVE ORGANS. 



good health, tend also to diminish this liability, and many a person 
will in his autumnal holiday expose himself with impunity to condi- 
tions which at home would certainly have brought on a severe attack. 
So far as possible, therefore, exercise and other health-conducive prac- 
tices should be enjoined. It is not, however, the exposure which 
attends active exercise that as a rule induces cold, unless, indeed, the 
patient has undergone great fatigue, and fails consequently to keep 
himself warm, but it is rather the exposure when one is still, especially 
when one is still after previous violent exertion, and exposed to a cool 
breeze, or to a cool draught of air, or to the coldness induced by wet 
clothes, or by the evaporation of sensible sweat. The means of obvi- 
ating such dangers are too obvious to need enumeration. It is gener- 
ally held, and we believe with reason, that a matutinal cold bath, fol- 
lowed by friction with a rough towel, and then by walking or other 
exercise, is a good preventive of the liability to colds. The shower- 
bath has been especially recommended for this purpose. It is, never- 
theless, a fact, that the continued use of the shower-bath will, in some 
persons, so far from obviating the liability to cold, induce it, and keep 
up a permanent catarrhal state. 



THRUSH. {Aphtha.) 

Causation and Morbid Anatomy. — Inflammatory affections of the 
mouth and fauces very frequently arise in connection with stomach and 
bowel disturbance, sometimes simultaneously with it, sometimes second- 
arily to it, and more rarely, perhaps, as the first step in the order of 
events. Such inflammations are sometimes catarrhal in the anatomical 
sense of the word, and hence not readily distinguishable in all cases 
from the effects of ordinary cold. They do not, however, so far as we 
know, tend, as the latter variety does, to involve the nasal cavity and 
the air-passages, or to extend either to the eye or to the ear or to the 
sockets of the teeth, or to the branches of the fifth pair; while, on the 
other hand, they involve the mucous membrane of the mouth much 
more prominently. 

The most trivial form of the affection now under consideration is 
that which is often observed in persons who are liable to dyspepsia. 
The dyspeptic symptoms, which are probably inflammatory, are at- 
tended with stiffness and soreness of the back of the tongue and fauces, 
and sometimes of the anterior part of the organ as well. There may 
be considerable pain on deglutition ; and acid or stimulating articles of 
diet, and such as are in hard and angular fragments, cause intolerable 
smarting. On inspection of the parts which are complained of, little 
or no visible departure from the healthy condition can in some cases be 
observed ; in other cases, however, there is more or less obvious red- 
ness ; and often very careful inspection will reveal the presence of 
cracks or fissures, or even of small patches of excoriation along the 
edges of the tongue, and elsewhere at the back of the mouth. 



THRUSH. 



585 



In young children, especially those at the breast, a somewhat similar 
condition is often met with in connection with gastro-intestinal disturb- 
ance and feverishness. The patient suffers from diarrhoea or irregu- 
larity of the bowels, frequent vomiting and inability or disinclination 
to take the breast. The lips are dry, and the tongue, especially at the 
tip and edges, redder and drier than natural, and with a tendency to 
become furred on the dorsum and towards the base. In many cases 
small excoriations or ulcers make their appearance on various parts of 
the oral and faucial surfaces. 

The most important form, however, which the affection assumes is 
especially characterized by the appearance in greater or less abundance 
over all parts of the mucous membrane of the mouth and fauces, on the 
tongue, gums, and palate, inside the lips and cheeks, on the soft palate, 
on the pillars of the fauces, and even on the surface of the pharynx, of 
small, elevated, opaque, whitish spots, which are round or irregular in 
form, pretty firmly adherent, and not unfrequently appear like adherent 
flakes of curdled milk. There is usually at the same time more or less 
congestion of the mucous surface, with dryness and furring of the 
tongue. These white patches can easily be detached, leaving a more 
or less distinctly excoriated area behind ; and appear to be due to in- 
flammatory overgrowth of the epithelium with tendency to its detach- 
ment. They are not improbably vesicular. In a large proportion of 
cases a cryptogamic plant which has been termed the oidium albicans, 
has been discovered flourishing in the aphthous patches; and hence by 
some aphtha has been regarded as a parasitic disease, or has been 
divided into two varieties, one parasitic, the other simply vesicular. 
It is not altogether clear what relation the plant holds to the disease. 
On the whole, however, looking to the circumstances under which 
aphtha occurs, to the rapidity with which in many cases it disappears 
without special treatment, and to the fact that the mucous membrane 
of the mouth is a fertile soil for the development of lowly vegetable 
organisms, we are disposed to regard the oidium albicans as a mere 
accident of aphtha and not as a cause of it in any of its varieties. 

Symptoms and Progress. — Aphtha is of very common occurrence in 
young children, more particularly infants at the breast ; but is frequent 
also in the course of many diseases, especially such as are attended with 
hectic fever or with the typhoid condition. In young children it is 
generally preceded by and attended with feverish symptoms — heat of 
skin, fretfulness, and drowsiness — diarrhoea, or other morbid conditions 
of the bowels, loss of appetite, vomiting, and unwillingness to take food. 
Gastro-intestinal disturbance, indeed, is rarely absent, and it is believed 
by many that aphtha of the mouth indicates a similar condition in the 
stomach and alimentary canal. The anus and its vicinity in such cases 
are sometimes reddened and excoriated, and aphthse have been de- 
scribed as existing there. Aphtha may subside after a few days, or 
last continuously or with remissions for many weeks. It is not in itself 
a dangerous affection or necessarily an indication of danger in the affec- 
tion which it attends. It must not be forgotten, however, that it fre- 
quently accompanies gastro-intestinal lesions which prove fatal, and 
that its presence cannot but add something to the clanger of a danger- 



586 



DISEASES OF THE DIGESTIVE ORGANS. 



ous disease. When aphtha supervenes in the course of diseases affect- 
ing adults, although it is not necessarily an indication of impending 
death, it is yet often a symptom of grave omen. 

Treatment. — In the treatment of aphtha and of the forms of inflam- 
mation related to it, it is important in the first place to attend to the 
general health and especially to the condition of the alimentary canal. 
In children it is generally best to commence the treatment with a dose 
of castor oil, or of rhubarb in combination with carbonate of magnesia 
or gray powder, and then to administer medicines calculated to im- 
prove the tone of the stomach and bowels. According to the particu- 
lar symptoms present may be prescribed lime-water with milk, small 
doses of rhubarb with ginger or some other aromatic, aromatic confec- 
tion with chalk and opium, or vegetable bitters. Locally, relief may 
be given by the application of mel boracis, solution of tannin, sulphate 
of zinc, or nitrate of silver; by washing out the mouth with a solution 
of chlorate of potash, by rinsing it with mucilaginous fluids, or by the 
use of lozenges containing gelatin or mucilage. With the object of 
destroying the parasite on which aphtha is supposed to depend, solu- 
tion of sulphurous acid has been strongly recommended. 



ULCERATIVE STOMATITIS. 

Causation and Morbid Anatomy. — A peculiar affection of the mucous 
surface of the cavity of the mouth is sometimes met with, chiefly if not 
entirely in children below the age of puberty, which has a close relation, 
at all events anatomically, to that observed in cattle affected with the 
foot-and-mouth disease. It is impossible to deny that there is also 
some resemblance between this affection and both thrush and the early 
stage of gangrenous ulceration. Yet the appearances are so peculiar, 
and the whole progress of the affection so like that of a specific disease, 
that there is good reason to regard it as an affection mi generis. It 
consists in the formation of excoriated patches, chiefly limited to the 
surface of the gums, and corresponding parts of the cheeks, but occur- 
ring also on the dorsum and sides of the tongue, mainly towards the 
base, on the palate, and on the general surface of the buccal mucous 
membrane. The excoriations vary in size and shape, but are mostly 
irregular and tending to run together; their surface is raw, red, and 
weeping, sometimes bleeding; and the surface of the mucous membrane 
between them is thickened and opaque. The tongue generally (ex- 
cepting the spots of excoriation) becomes covered with a thick, tough, 
opaque, whitish fur, and its surface looks not unlike a piece of wash- 
leather. 

Symptoms and Progress. — The approach of the malady is usually 
indicated by some degree of feverishness and malaise, symptoms, in- 
deed, differing little if at all from those that usher in an ordinary cold. 
Then, after a day or two, some soreness is experienced in masticating, 
speaking, and deglutition ; and if the mouth be examined, the morbid 



NOMA — GANGRENE OF FAUCES. 



587 



phenomena above described will be recognized in an early stage. The 
progress of the affection is attended with febrile symptoms — heat of 
skin, flushing of face, listlessness, drowsiness, thirst, loss of appetite, 
and the like. And these, together with the local affection, usually tend 
to subside in the course of a week or ten days. In some cases the 
affection of the mouth assumes a more chronic character. We are not 
aware that it ever leads to serious consequences. 

Treatment — For local treatment mel boracis, or chlorate of potash 
in solution, seems to be indicated. Internally, a little chlorate of potash 
or other febrifuge medicine may be administered. 



NOMA. (Gangrenous Stomatitis.) GANGRENE OF FAUCES. 

1. Noma. Causation. — Gangrenous ulceration of the mouth is an 
occasional and very dangerous affection. It occurs almost exclusively 
in children under twelve years of age, and indeed is mainly limited to 
those whose ages lie between one and five. Its cause is not very 
obvious. There is no doubt, however, that it is especially apt to be- 
come developed during convalescence from acute febrile disorders, 
among which measles stands pre-eminent, and in children who have 
been badly fed or are ansemic. 

Morbid Anatomy. — The gangrene may commence at any part of the 
buccal surface, and in several parts at one time. But it usually origi- 
nates in the sulci between the gums and cheek, and chiefly (according 
to Barthez and Rilliet) in that of the lower jaw\ It begins variously, 
sometimes with ulceration or the formation of a superficial slough of 
the mucous membrane, sometimes with congestion, thickening, and 
tension of the substance of the cheek or other soft parts circumscribing 
the oral cavity. In any case there soon appears on some part of the 
mucous surface of the mouth an irregular grayish or black sloughy 
patch surrounded with a rim of intense and somewhat livid congestion. 
This tends to spread rapidly both in area and in depth, its extension 
being preceded and accompanied by infiltration, hardening, and con- 
gestion of the tissues. The cheek in the affected neighborhood fre- 
quently becomes tense, shining, and livid. With the extension of the 
gangrene, the gums may be destroyed, the alveoli necrosed, and if the 
patient live sufficiently long, the teeth and portions of the jaw may 
come away, and the soft palate, fauces, and tongue, each and all, be 
more or less extensively destroyed. Very frequently the cheek be- 
comes perforated, and the destructive process may then spread almost 
indefinitely, involving in turn the mouth, the entire cheek, and it may 
be the nose, the eye, and other contiguous parts. 

Symptoms and Progress. — The symptoms which attend noma are, at 
all events in many cases, much less severe than one would expect them 
to be. It often happens that the gangrene has made some progress in 
the interior of the oral cavity before anything has occurred to call 
special attention to what is going on there ; and indeed it is not a rare 



588 • DISEASES OF THE DIGESTIVE ORGANS. 



thing to find patients in whom gangrene has committed the most ex- 
tensive and frightful ravages, and for whom recovery is hopeless, who 
neither suffer pain nor have suffered it, who maintain a good appetite, 
and continue sensible and even cheerful. The special symptoms, in 
addition to swelling of the cheek and the actual progress of the gan- 
grene (which is obvious enough if looked for), are : more or less pro- 
fuse salivation, the discharge often being bloody and foul ; extreme 
fetor of this discharge and of the breath ; and more or less swelling of 
the neighboring lymphatic glands. As above indicated, the patient 
often suffers very little pain or uneasiness, remains sensible, talking 
and taking an interest in what is going on round about him, and retains 
his desire for food, and the power of taking it. But notwithstanding 
this, the pulse rises in frequency and becomes small and feeble : the 
surface grows pale and cold ; drowsiness or delirium comes on ; diar- 
rhoea perhaps sets in ; and death from asthenia supervenes at the end 
of a few days. In a small proportion of cases recovery takes place, 
with more or less deformity. 

2. Gangrene of Fauces. Causation. — But gangrene, not specially 
limited in this case to young children, may commence in the fauces or 
the pharynx. In some cases this is due to diphtheria or scarlet fever, 
or may result from the mere intensity of the inflammation in ordinary 
tonsillitis. But it may also occur independently of such special diseases, 
and may, like noma, be traceable to profound impairment of the general 
health. 

Symptoms and Progress. — The symptoms in these various cases differ 
in some degree according to the nature of the disease to which the 
gangrene is due. Eliminating, however, the symptoms referable to the 
several specific affections which have been named, gangrene of the 
fauces w 7 ould be revealed by tumefaction of the tissues, the appearance 
of sloughs upon the surface, fetid discharge and fetid breath, swelling 
of the glands beneath and behind the jaw, and, in addition to these 
phenomena, difficulty and pain in deglutition, and probably, before 
long, more or less difficulty of respiration. The situation of the morbid 
process necessitates the presence of much more pain and discomfort than 
are usually associated with noma; and here, as in the other case, very 
extensive destruction of tissue may take place, and perforation ensue. 
The general symptoms are: feebleness of pulse, sometimes with quick- 
ening, sometimes with marked diminution of frequency; pallor, coldness 
of surface, tendency to collapse, and not unfrequently before death, 
copious perspirations, diarrhoea, and impairment of consciousness, 
delirium, or coma. 

Treatment. — In treating gangrenous affections of the mouth and 
throat, it is in the first place of paramount importance that the patient's 
strength should be maintained by the regulated administration of nutri- 
tious food and alcohol, and of tonic medicines, or these combined with 
diffusible stimulants. Opium here, as in all similar cases, may be of 
great service. For local treatment, it is necessary to keep the parts 
cleansed, to wash them frequently with antiseptic fluids, such as solu- 
tions of either chlorinated soda, chlorine, hydrochloric acid, perman- 



INFLAMMATION OF GUMS IN DENTITION 



— GLOSSITIS. 



589 



ganate of potash or chlorate of potash; and to treat the gangrenous 
tracts themselves freely with eseharotics, of which probably the most 
valuable are pure hydrochloric or nitric acid, and the actual cautery. 



CONGESTION AND INFLAMMATION OF THE GUMS IN 

DENTITION. 

Cutting the teeth is always attended with more or less discomfort, if 
not absolute pain. Generally, previous to the actual eruption, the im- 
plicated gum becomes congested, swollen, and tense, and often distinctly 
inflamed. Occasionally suppuration or ulceration takes places. The 
eruption of the second teeth is rarely attended with symptoms which 
call for the notice of the physician. The eruption of the first set, how- 
ever, is a fertile source of infantile ailments. This is especially the case 
when it is of unusually early occurrence. It is well known to mothers 
and nurses that infants who are on the eve of cutting their teeth begin 
to dribble and to bite the finger or any other hard substance which 
may be introduced into the mouth; and looking upon these symptoms 
as an indication for treatment, they give the babe an ivory or india- 
rubber ring, or a piece of coral to bite. 

So far the symptoms may be regarded as normal; but in many cases 
the congestion of the gum produces feverishness and fretfulness, inter- 
feres with the infant's rest, and induces sickness and diarrhoea. When 
these phenomena ensue, each may be treated according to its impor- 
tance; the vomiting may be allayed by the exhibition of some aromatic, 
or the addition of a small quantity of lime-water to the milk; the 
diarrhoea may be rectified by the administration of a little castor oil or 
Gregory's powder, followed, if necessary, by a little aromatic confection 
and chalk; the restlessness may be met by minute doses of opium. In 
the great majority of cases, however, the most efficacious and the best 
treatment is to freely lance the inflamed gum. 

In some instances convulsions are referable to the irritation of the 
emerging teeth. Under such circumstances, in addition to the appro- 
priate treatment for convulsions, lancing of the gums must be efficiently 
performed. 

Many other maladies besides the above are commonly regarded as 
the effects of dentition, the principal of them being eczema, lichen and 
impetigo in various forms, bronchitic affections, and paralysis. It is 
doubtful, however, whether dentition has any other effect over them 
than that of aggravating them. 



GLOSSITIS. 

Causation. — Besides the superficial forms of inflammation in which 
the tongue shares with the other parts bounding the oral cavity, the 



590 



DISEASES OF THE DIGESTIVE ORGANS. 



organ is liable to become inflamed throughout its whole substance. 
This occurrence, which is rare, may take place under the influence of 
mercurial poison, or as a consequence of direct injury, but now and 
then arises independently of all such obvious causes. 

Symptoms and Progress. — Idiopathic glossitis is said to be preceded 
in soine cases by premonitory febrile symptoms. In other cases the 
inflammation is certainly, so far as one can judge, primary, although 
attended probably from the commencement with more or less febrile 
disturbance, and sometimes with rigors. It sometimes commences in 
the tongue itself, at other times in the neighboring parts, especially 
the fauces, whence it spreads to the tongue. The latter then becomes 
swollen, stiff, and painful, and incapable of executing its proper func- 
tions. The swelling is usually general, although sometimes limited to 
one-half, or some lesser portion. The organ becomes enlarged in all 
its dimensions, so thick sometimes as to render inspection of the back 
of the mouth out of the question, so wide as to project between the 
molar teeth, so long as to protrude beyond the lips, sometimes indeed 
exerting also serious pressure upon the upper part of the larynx. The 
pain is usually of a throbbing or burning character, and increased by 
all attempts at movement, so that mastication, deglutition, and articu- 
lation become in some cases almost impossible. Saliva accumulates in 
the mouth, and the patient's sufferings consequently become much 
aggravated. The surface of the tongue may in the first instance be 
redder than natural, but very soon gets enveloped in a thick, white, 
creamy fur. Occasionally suppuration takes place and an abscess 
forms. The affection usually attains its height in the course of three 
or four days, and, if free from complication, subsides in the course of 
a week or ten days. Permanent hypertrophy of the tongue has some- 
times resulted. 

The sufferings of a patient with glossitis are usually out of propor- 
tion to his danger. Some of them have been already referred to ; but 
one of the most serious is the sense of impending suffocation which is 
often present, and which alone may be sufficient to prevent all sleep 
and forbid even temporary ease. It is quite possible, however, that 
from extension of oedema or inflammation to the larynx dangerous 
symptoms, and death even, may ensue. The disease, therefore, is one 
that needs close and careful supervision. 

Treatment. — The patient should have his mouth cleansed, by gargling 
(if he can effect it) or otherwise, with solution of chlorate of potash or 
other detergent lotions; his strength should be sustained with liquid 
nourishment, wdiich, if it cannot be swalluwed, should be administered 
by the nose or rectum. Fomentations may be applied to the throat 
externally, and leeches even may be deemed advisable. It may also 
be necessary (and the practice is very efficacious) either to apply leeches 
to the tongue itself, or to make longitudinal incisions into it. If an 
abscess form, it should, of course, be opened. Febrifuge general treat- 
ment may be adopted ; and of drugs there is no doubt that opium is 
of paramount value. It requires, however, to be given with much 
caution. If suffocation threaten, tracheotomy must be performed. 



QUINSY. 



591 



QUINSY. {Tonsillitis.) 
Acute Tonsillitis. 

The surface of the tonsil becomes inflamed in a greater or less degree 
whenever spreading or general inflammation involves the mucous mem- 
brane of the mouth and fauces. Hence, in catarrh, aphtha, and the 
like, the tonsils are necessarily to some extent implicated. Again, there 
are several affections in which the inflammatory involvement of the 
substance of the tonsils forms an important and characteristic feature. 
We especially refer here to scarlet fever and diphtheria. Deep-seated 
or parenchymatous inflammation of the tonsils, however, is, like ordi- 
nary catarrh, a frequent consequence of exposure to cold or wet — the 
two conditions, indeed, are not unapt to concur. Nevertheless it is a 
fact that many persons who are subject to catarrh, with all its usual 
associations, never suffer by any chance from tonsillitis; and it is 
equally a fact that tonsillitis often occurs independently of the special 
symptoms of catarrh. The symptoms and course of tonsillitis, more- 
over, are very characteristic, and the affection, therefore, calls for inde- 
pendent consideration. Tonsillitis is mostly a disease of childhood, 
but when once it has been developed, it is peculiarly apt to recur, and 
thus to be perpetuated into the period of adult life. 

Morbid Anatomy. — Simple or non-specific inflammation of the ton- 
sils is characterized by inflammatory swelling of the tonsils themselves 
and of the soft tissues in their immediate neighborhood, especially of 
the pillars of the fauces, the soft palate and uvula, the base of the 
tpngue and the pharynx. The tonsil (for one is generally first and 
often solely affected) becomes increased in size, deeply congested, and 
infiltrated with inflammatory exudation and growth. The crypts upon 
its free surface produce superabundant epithelium, which accumulates 
in their orifice, forming opaque, yellowish, creamy pellets. The lym- 
phatic nodules of the interior undergo inflammatory overgrowth, soften, 
suppurate, and run together. Ultimately they form an abscess. The 
soft palate and the pillars of the fauces become of a vivid-red hue, 
swollen, tense, and shining, and more or less displaced. Thus, if the 
swelling of the tonsil and of the surrounding parts be extreme, we 
find the soft palate on the affected side pushed downwards, forwards, 
and inwards, the anterior faucial pillar correspondingly displaced, and 
both together forming a smooth, tense, vividly red swelling, with the 
convexity facing forwards. The swelling and displacement of the 
surrounding parts are indeed sometimes so great that the enlarged 
tonsil itself is almost concealed. When both tonsils are involved, 
their affection is sometimes concurrent, more frequently in sequence. 
Often, indeed, the one is getting well when its fellow first shows signs 
of disease. When the tonsils are both very large, they may meet one 
another in the mesial line, becoming flattened and sometimes ulcerated 
from mutual pressure, and between them serving almost completely to 
close the faucial canal. The uvula, which is usually swollen, tense, 
and congested, often clings to one of the tonsils ; it may be so much 



592 



DISEASES OF THE DIGESTIVE ORGANS. 



elongated as to bang pendulous into the upper part of the larynx. 
Further, the tongue becomes covered with a thick creamy fur, and the 
glands at the angle of the jaw, and sometimes the salivary glands share 
in the inflammation, and become large and hard. 

Symptoms and Progress. — The invasion of tonsillitis is almost always 
marked by the occurrence of severe febrile symptoms, associated with 
soreness, itching or tingling, dryness and aching in the region of the 
fauces. The febrile symptoms increase in severity with the onward 
progress of the local affection, and with this latter gradually or, it may 
be, suddenly subside. At the beginning the patient experiences alter- 
nate flushes of heat and chills, and it may be actual rigors ; his tem- 
perature rises, and often reaches an elevation of at least 102° ; not un- 
frequently, indeed, by the time the disease has attained its maximum, 
it reaches 104° or even 105° and upwards; his pulse increases in fre- 
quency, mounting from 100 to 120, and is at the same time more or 
less full and firm; his skin is hot and pungent, but with a marked 
tendency to remittent sweats; he complains of headache, pains in his 
back and limbs, thirst and anorexia; his bowels are confined, his urine 
dark-colored and scanty. The appearances which the tonsils and the 
interior of the mouth present may be gathered from the description 
which has been already given of these parts. It remains to say that 
the patient has severe pains at the back of the throat and base of the 
tongue whenever he moves his jaws, whenever he speaks, and especi- 
ally whenever he opens his mouth widely or attempts to sw T allow. 
The pain then not unfrequently shoots along the Eustachian tubes to 
the ears. He has a constant desire to swallow in order to relieve his 
uneasiness, but the pain and difficulty of swallowing are so great that 
he permits the secretions to accumulate within his mouth; and, in al^ 
tempting to swallow, fluids not unfrequently pass up into the nose. 
The quality of the voice is nasal and characteristic. There is often 
deafness, and always more or less fulness and tenderness behind the 
angles of the jaw. The swollen tonsils themselves may indeed be felt 
in these situations. If one tonsil only be inflamed, or both be simul- 
taneously affected, the malady will probably attain its height in three 
or four days, and end in convalescence at the end of a week or ten days. 
Occasionally its course is yet more rapid, and the patient is well, or 
nearly so, in three or four days. But when one tonsil is affected after 
another, the course of the malady is necessarily protracted. If an ab- 
scess form, as is usually the case when the attack is severe, the severity 
of the symptoms progressively increases up to the moment at which 
the abscess breaks. Then the tonsil suddenly shrinks within moderate 
dimensions, and the patient is probably at once restored to compara- 
tively good health. The matter which escapes is fetid and thick, and 
is usually swallowed. The symptoms of tonsillitis are always severe 
out of all proportion to the seriousness and danger of the affection. 
Any other termination than that of recovery within a brief period is 
almost unknown. The interference with swallowing, which seems so 
serious, never prevents the taking of food for more than a very liniited 
period. The threatening of suffocation very rarely indeed becomes re- 
alized. 



CHRONIC TONSILLITIS. 



593 



Treatment. — Tonsillitis is one of that large number of diseases which 
takes its own course. It may, nevertheless, be relieved by appropriate 
measures. The patient should be submitted to the same plan of gen- 
eral treatment that has been already recommended as suitable for ca- 
tarrh, the details of which need not be repeated. Nor need there be 
much difference in respect of local treatment. Hot fomentations, or 
flannel or cotton-wool may be applied to the exterior of the throat; and 
the patient be persuaded to gargle his fauces frequently with warm 
milk, or to allow the steam of boiling water to play upon them, or to 
suck black-currant jelly and such-like substances. Swallowing lumps 
of ice, however, and the application of ice-cold compresses to the neck 
often gives far greater relief than warmth. Astringent and stimulat- 
ing gargles are often recommended, as also is the application of nitrate 
of silver. Such treatment, however, is more suitable to the period of 
convalescence, at which time also tonics and good food may be speci- 
ally needed. Opium judiciously administered generally gives great re- 
lief. When the swelling of the tonsil is extreme and the congestion 
intense, and at the same time the patient is suffering severely, relief 
may sometimes be afforded by scarifying or puncturing the tonsil. The 
value of such treatment, however, is chiefly seen when suppuration has 
taken place. Care should be exercised in puncturing the tonsil not to 
wound the large vessels which run along its outer aspect. The point 
of the lancet should be directed backwards, with an inclination inwards. 
But even if no large vessel be injured, dangerous hemorrhage occasion- 
ally ensues. 

Chronic Tonsillitis. 

Symptoms and Progress. — As a consequence sometimes of frequently 
repeated attacks of acute tonsillitis, sometimes of chronic inflammation, 
the tonsils undergo gradual hypertrophy, and form indolent tumors, 
which more or less seriously diminish the size of the faucial passage, 
and occasionally come into actual contact with one another. The 
presence of such tumors is sometimes scarcely apparent to the patient 
himself; but in many cases, especially if large, they give a peculiar 
quality to the voice, which is indescribable, but impossible not to 
recognize when once it has been pointed out; and not unfrequently 
there is associated with them some chronic thickening of the mucous 
membrane of the pharynx and of that of the Eustachian tubes, with 
more or less deafness. Further, such patients are generally liable to 
frequent exacerbations of the affection. 

Treatment. — Tonic medicines, iron and quinine and the like, good 
diet, fresh air, and healthful exercise are of essential value in the treat- 
ment of chronic tonsillitis. It is commonly held that the application 
of strong solutions of nitrate of silver or of the solid caustic, or of other 
such agents, is serviceable in promoting the disappearance of these 
bodies. Such applications are no doubt frequently beneficial in allay- 
ing inflammation affecting their surface. But the only effectual way 
of dealing with them is to remove them by the knife. 



88 



591 



DISEASES OF THE DIGESTIVE ORGANS. 



RETROPHARYNGEAL ABSCESS. 

Causation. — Retropharyngeal abscess is usually due to caries of the 
cervical vertebrae, and is sometimes one of its earliest indications; it 
may be connected, also, we believe, with suppuration in and about 
the tympanum and Eustachian tube, even when the bone is not in- 
volved. 

Symptoms and Progress. — A retropharyngeal abscess, as its name 
indicates, is situated between the posterior wall of the pharynx and the 
anterior aspect of the vertebra?, and forms a convex protrusion of 
greater or less extent and prominence at the back of the pharynx. It 
may be so high as to escape detection by the usual method of observa- 
tion, it may be so low as equally to escape recognition ; in most cases, 
however, it forms a visible bulging at the back of the throat. It is 
sometimes symmetrical, sometimes more or less one-sided, soft, and 
yielding to the touch, and not necessarily presenting superficial con- 
gestion. It is liable to undergo perforation from time to time, to allow 
of a more or less free temporary escape of matter, and consequently to 
vary in bulk. Its presence is sometimes productive of pain and diffi- 
culty in swallowing, and has been known to impede respiration and 
even to cause death by such impediment; but not unfrequently it is, for 
a time at least, simply a source of discomfort to the patient, in conse- 
quence of the pus which it exudes, the foul taste which it consequently 
gives, and the fetor which it imparts to the breath. The progress of 
the abscess mainly depends on that of the disease which produces it. 

The treatment, apart from the use of tonics, which is generally 
clearly indicated, is essentially surgical. 



OZ^ENA. 

Causation. — This term is applied to all those cases which are 
attended with fetid discharge from the nose. The causes of ozsena are 
in some cases mere chronicity of inflammation of the mucous surface, 
in some cases ulcerative destruction or gangrene, and in a large pro- 
portion of cases caries or necrosis of the nasal bones. These several 
morbid conditions are for the most part connected either with a scrofu- 
lous condition, with syphilis, or with lupus, or with polypoid or 
malignant growths occurring in the nasal cavities. 

Symptoms. — The discharge which escapes from the nostrils varies 
considerably both in character and quantity. Sometimes it differs 
little in appearance from ordinary mucus, often it is thick and puru- 
lent, sometimes it contains blood, sometimes it is thin and ichorous. 
It frequently also tends to concrete in the cavities of the nostrils into 
thick crusts. The accumulation of unhealthy discharges in the antrum 
and other sinuses connected with the nose often leads to their decom- 
position, and to fetor ; and the escape of such discharges is apt to take 
place at irregular intervals. The nature of the stench which is emit- 



MORBID GROWTHS. 



595 



ted varies greatly both in quality and in intensity. In some cases it 
is horribly disgusting. The presence of ozrena is generally attended 
with more or less complete loss of the power of smell. 

The determination of the source of the ill smell may, even in the 
absence of discharge, be readily ascertained by making the patient 
respire alternately through the mouth and nose, and ascertaining under 
which of these conditions it is chiefly developed. 

Treatment. — For this purpose the determination of the cause is of 
fundamental importance. If it be syphilitic, antisyphilitic remedies 
must be given ; if connected with enfeebled constitution, tonics and 
good diet must be enjoined. Under any circumstances the nose should 
be kept clean ; it should be frequently washed out by means either of 
a syringe or the nasal douche, with a weak alkaline solution, or a 
weak solution of quinine, Condy's fluid, chlorinated soda, or chlorate 
of potash ; and either stronger solutions of the same agents should be 
occasionally employed as injections, or appropriate powders frequently 
blown in or sniffed up. For the latter purpose Trousseau especially 
recommends bismuth diluted with an equal part of some inert powder, 
or white precipitate mixed with about forty times its weight of finely- 
powdered sugar. 



MORBID GROWTHS. 

1. Tubercle. — Miliary tubercles are described by Virchow as occa- 
sionally affecting the mucous surface of the tongue, the palate, and the 
nose, and there producing shallow sinuous ulcers, such as characterize 
the tubercular process in other mucous membranes. It need scarcely 
be said that miliary tubercles would be difficult of recognition in these 
situations during life ; at the same time it is a fact that shallow, in- 
tractable ulcers, not improbably due to this cause, are not altogether 
uncommon in the fauces and soft palate of phthisical patients, even at 
an early period of their disease. 

2. Syphilis. — Syphilis, in its secondary and tertiary stages, is very 
apt to affect the tract of mucous membrane now under consideration. 
(a) Erythematous patches, for the most part symmetrical, may appear 
on the pharynx, on the palate, inside the lips, or elsewhere in the mouth 
during the prevalence of the secondary cutaneous eruption. (6) Mu- 
cous tubercles may become developed during the same period, princi- 
pally on the lips, the dorsum and edges of the tongue, the tonsils, and 
the palate, and in the pharynx ; and shallow ulcers, secondary to these 
tubercles, or of independent origin, are not unfrequent in the same 
situations, (c) At a later period of the disease deep ulcers appear, 
most commonly in the soft palate, the tonsils, fauces, and pharynx, 
spreading frequently in a serpiginous manner, and either gradually 
involving a wide extent of surface or penetrating deeply, and in either 
case leading to serious destruction of tissue, (c?) Lastly, gummatous 
tumors are not uncommonly developed in the soft palate, in the phar- 
ynx, and more especially in the substance of the tongue. 



596 



DISEASES OF THE DIGESTIVE ORGANS. 



For a further account of these affections, and their treatment, we 
must refer to the article upon syphilis. 

3. Malignant Tumors. — Tumors of various kinds originate in, or 
involve, the mucous membrane of the mouth and fauces, or the organs 
which are contained within the mouth. It scarcely, however, falls 
within the province of the physician either to investigate or to treat 
them. Malignant affections of these parts, indeed, have alone any 
medical interest. They are not uncommon. 

In persons advanced in years, epithelioma of the lips (more especi- 
ally of the lower lip) is apt to occur ; in those who have attained or 
passed middle age a similar affection of the tongue is not uncommon ; 
and not unfrequently also under the same circumstances malignant 
disease, mostly epithelioma, but sometimes carcinoma, sometimes sar- 
coma, becomes developed in some part of the fauces or pharynx. Again, 
malignant tumors (commonly some soft variety of carcinoma or sar- 
coma) occasionally form in connection with the mucous membrane of 
the nose, for the most part in young children or in persons who are 
advanced in life. Further, sarcomatous and carcinomatous tumors 
originating either in periosteum or bone form outgrowths from the 
bones of the upper and lower jaws, from those bounding the nasal 
cavity, and also from the cervical vertebrae. 

Malignant tumors of the mucous membrane are nearly always pri- 
mary; they are often slow and insidious in their progress, and apt at 
first to be mistaken for some trivial affection ; they are especially liable 
when they have made some progress to be confounded with syphilitic 
affections. It is, indeed, often quite impossible to recognize their true 
character in the absence of careful microscopic examination. That they 
are not syphilitic is, however, soon revealed by the total inoperativeness 
upon them of antisyphilitic treatment, and by their further progress. 
They gradually and surely invade the surrounding textures, gradually 
ulcerate and slough, causing more and more extensive destruction, yield 
a foul discharge, and always before long involve the neighboring lym- 
phatic glands. These then form gradually enlarging tumors, which 
presently undergo precisely the same changes as the primary tumor. 
The diagnosis of these cases, which is often very uncertain in the be- 
ginning, rests mainly upon microscopic examination and on careful 
observation of their gradual and characteristic progress. 

Their treatment is purely surgical. 



(2.)— DISEASES OF THE (ESOPHAGUS. 
INTRODUCTORY REMARKS. 

Anatomical Relations. — The oesophagus commences at the cricoid 
cartilage, opposite the lower border of the fifth cervical vertebra, and 
runs down along the spine, a little to the left side, as far as the ninth 
dorsal vertebra, opposite which it penetrates the diaphragm and opens 



DISEASES OF THE (ESOPHAGUS. 



597 



into the stomach. In the neck it has the trachea in front of it, with 
the recurrent laryngeal nerves between them, and on either side the 
common carotid artery. In the chest it is covered in front by the 
lower part of the trachea and then crossed by the left bronchus, after 
which it is in contact with the pericardium. On either side of it is 
the pleura. The transverse and descending arch of the aorta cross 
the front and left side of the oesophagus on the level of the second 
and third dorsal vertebra? ; the thoracic portion of the vessel lies to 
the left of the oesophagus and behind it throughout the rest of its 
course, excepting just as the oesophagus perforates the diaphragm, 
when the aorta slips altogether behind it. 



INFLAMMATION. 

Causation. — The oesophagus is liable to share to a greater or less ex- 
tent in all those inflammatory conditions which affect the pharynx 
and larynx. We have pointed out that the inflammation of a simple 
" cold " may travel downwards along this tube ; and when inflammation 
of special intensity involves the organs in relation with it, the oesopha- 
geal inflammation itself may be equally intense. Occasionally, indeed, 
under such circumstances thickening of its walls with purulent infil- 
tration of them and of the surrounding connective tissue may extend 
from the pharynx to the cardiac orifice of the stomach. Further, the 
specific eruptions of some of the infectious fevers may involve the 
oesophagus, the diphtheritic false membrane may pervade its whole ex- 
tent, and aphthous patches may form here and there upon it. Inflam- 
mation is also sometimes the result of swallowing boiling water or corro- 
sive substances, such as the mineral acids, the caustic alkalies, and 
other chemical agents. 

Symptoms. — In nearly all these cases the oesophageal inflammation is 
associated with similar but probably more severe inflammation, either 
of the larynx, pharynx, and fauces above or of the stomach below ; and 
the graver symptoms of these other affections tend to mask more or 
less completely the presence of the oesophageal complication. The 
special indications of inflammation of the oesophagus are the presence 
of heat and pain in the course of that tube; aggravation of pain in the 
same situation during the act of swallowing, and in very severe cases 
inability to swallow ; tenderness also on pressure applied to the neck 
in the situation of the oesophagus. The absence, however, of such 
symptoms does not exclude the presence of either general slight inflam- 
mation, or of limited tracts of inflammation. 



CHRONIC AFFECTIONS OF THE (ESOPHAGUS. 

1. Ulcerative Inflammation. 

Causation and Morbid Anatomy. — The most frequent cause of ulcer- 
ation is either mechanical violence or the operation of destructive re- 



598 DISEASES OF THE DIGESTIVE ORGANS. 

agents, to which may be added perforation of the oesophagus from 
without. 

Small ulcers and mere excoriations doubtless, as a rule, get well with- 
out leaving any permanent ill effects behind ; but when ulcers are ex- 
tensive and deep, then (even though they be free from any malignant 
taint) they are liable sooner or later to induce serious results. Of these 
the most important is cicatrization with consequent contraction of the 
calibre of the tube, and the supervention of a stricture which tends as 
a rule to become more and more tight. Other results are the formation 
of a sinus between the oesophagus and the trachea, or the left bronchus, 
and the perforatian of an artery. 

2. Morbid Growths. 

Morbid Anatomy. — The oesophagus is occasionally the seat of syphil- 
itic ulceration, which by its contraction may cause more or less serious 
obstruction of that tube. Of all adventitious formations, however, 
the most common and most serious are of a malignant character. These 
are especially common after the age of 40 or 45, and in the great ma- 
jority of cases are of primary origin. The most frequent variety of 
malignant disease, probably, is epithelioma, but encephaloid and scir- 
rhous cancers are not unfrequent. Colloid cancer has been observed. 
The seat of the disease is very various. In some cases it occupies the 
upper extremity of the tube, probably then involving also the con- 
tiguous pharynx and larynx ; in some cases it is found at the lower 
extremity, in which case it is not unfrequently associated with similar 
disease of the neighboring part of the cardiac extremity of the stomach ; 
in the greater number of cases, however, it occurs in some intermediate 
spot, and very frequently in that part of the tube which is in relation 
with the trachea and bronchi. The affection, when primary, usually 
commences at some spot in the thickness of the mucous and submucous 
tissue, whence it spreads superficially, so that before long it probably 
comes to occupy three or four inches of the length of the oesophagus 
and its whole circumference ; and in depth, so that sooner or later the 
whole thickness of the walls is implicated, and the growth probably 
also invades the trachea or other neighboring tissues and organs. The 
growth on its free aspect is at first somewhat nodulated ; but the nodules 
running together soon form more or less flattened elevations, in connec- 
tion with which, before long, ulceration, sloughing, and the formation 
of fungous outgrowths take place. The thickened walls and nodulated 
outgrowths reduce the calibre of the oesophagus, and sometimes render 
it almost impervious. The subsequent ulcerative destruction occasion- 
ally leads to the imperfect restoration of its channel. When the dis- 
ease is of the colloid variety, the close-set vesicles of the growth be- 
come laid open on the mucous surface, and abundant, clear, glairy fluid 
consequently escapes. 

In the progress of malignant disease various accidents are apt to su- 
pervene. Sometimes the trachea or left bronchus becomes perforated 
and a more or less free communication between it and the oesophagus 
established ; sometimes the oesophagus opens into the posterior medias- 



DISEASES OF THE (ESOPHAGUS. 



599 



tinum, or externally, and sometimes communicates by ulceration with 
an artery, either one of the oesophageal, or intercostal or the left sub- 
clavian. But besides the mere spread by contiguity,, oesophageal, like 
other malignant growths, soon cause secondary disease in the neighbor- 
ing lymphatic glands, and in some cases, if the patient survive suffi- 
ciently long, disease of remote organs. The involvement of the lym- 
phatic glands, especially if they be those of the neck, is very often 
valuable as an aid to diagnosis. Further, it not very unfrequently 
happens that the recurrent laryngeal nerve, especially that of the left 
side, becomes implicated, and paralysis of the corresponding vocal cord 
induced. 

3. Affections implicating the OEsophagus from ivithout. 

Morbid Anatomy. — The oesophagus is necessarily apt to be pressed 
upon or otherwise affected by tumors and other morbid conditions 
originating externally to it. The patient's sufferings, indeed, in many 
such cases are mainly, if not entirely, due to interference with the func- 
tions of this canal. Thus it may be compressed by an overgrown thy- 
roid body encircling the trachea and acting upon it laterally ; by a 
carotid or innominate aneurism, or an aneurism of the descending arch 
or thoracic aorta ; by enlargements of the bronchial glands and other 
mediastinal growths ; by tumors springing from the vertebrae; by ab- 
scesses; and even by a distended pericardium or dilated auricles. 

Aneurisms and abscesses not unfrequently open into the oesophagus 
with a sudden and copious escape of blood or pus ; occasionally they 
open simultaneously into the oesophagus and trachea or one of the bron- 
chi, causing more or less free communication between these tubes; and 
further, rupture of an aneurism of the lower part of the thoracic aorta 
occasionally causes an accumulation of coagulum around the lower end 
of the oesophagus with complete obstruction of its passage. 



4. Dilatation of the (Esophagus. 

Causation and Morbid Anatomy. — Whenever a stricture of the oesoph- 
agus has existed for any length of time, a tendency shows itself for 
the part of the tube below to contract and even to undergo atrophy, and 
for the part of the tube above to become dilated and at the same time 
hypertrophied in respect of its muscular parietes. The same results in- 
deed follow here as follow in the case of the bladder when there is 
stricture of the urethra. This dilatation and hypertrophy are in the 
majority of cases not strikingly apparent ; sometimes, however, they 
are considerable, and especially so when the stricture is situated low 
down, is non-malignant, and has been in existence for many years. 
Under such circumstances the oesophagus becomes dilated either in its 
whole length, or in a part of its length only, forming an elongated 
pouch. It may attain a circumference of five or six inches. Such 
dilatations are sometimes discovered in cases where their development 
cannot be traced to the existence of any mechanical impediment. It 
seems obvious, however, that they must even here be due partly to 



600 



DISEASES OF THE DIGESTIVE ORGANS. 



distension by accumulated contents, and partly to powerful and sus- 
tained efforts of the muscular tunic to drive these contents onwards ; 
and that hence there must have been in the first instance some weak- 
ness or sluggishness of the tube, some virtual impediment permitting 
of such accumulation. 

5. Spasmodic and Paralytic Affections. 

1. Spasmodic stricture of the oesophagus generally occurs in nervous 
persons, and especially in hysterical women. It may, however, appear, 
without obvious cause, in persons of quite different nervous organiza- 
tion; and not unfrequently supervenes in the course of organic oeso- 
phageal disease, causing temporary aggravation of the patient's symp- 
toms. 

2. Paralytic conditions of the oesophagus are rare. They may be hys- 
terical or dependent on profound affection of the central nervous organs. 

Symptoms of Chronic (Esophageal Disease. Dysphagia. 

A common symptom of nearly all the lesions, the morbid anatomy 
of which has now been pretty fully discussed, is dysphagia; or difficulty 
and pain in swallowing. It is this symptom, indeed, which generally 
first attracts attention to the oesophagus as the seat of disease, and it is 
only by the subsequent history of the case, by the supervention or non- 
supervention of other phenomena, oftentimes mere hints, that we are 
enabled, with more or less accuracy, to ascertain the exact nature of 
the disease which is present. 

But dysphagia is a symptom of many other morbid conditions be- 
sides these. Many of the diseases also which affect the mouth, fauces, 
larynx, and pharynx are attended with more or less dysphagia. But 
dysphasia due to morbid states of the pharynx and parts anterior to 
or above the pharynx, is for the most part to be regarded as a symptom 
only of diseases already sufficiently obvious, and needs therefore no 
special consideration here. It is very different, however, when the im- 
pediment to swallowing exists in the course of the oesophagus ; it is 
then not merely a symptom, but it is the symptom by which alone, in 
many cases, the presence of disease is indicated. 

The symptoms of organic stricture are usually of slow development ; 
the patient first perhaps observes an occasional hitch in the passage of 
food to the stomach, a hitch which is chiefly obvious when solids are 
being swallowed. This is variable, partly because the bulk and char- 
acter of the swallowed bolus differs from time to time, and partly from 
the occasional superaddition of more or less spasmodic contraction. It 
is important, too, to note that the hitch is always referred to a certain 
point, and is not unfrequently associated with more or less well-marked 
soreness or pain there. For some time probably these symptoms have 
little attention bestowed upon them ; but gradually they increase in 
severity, become more constant, and attend the swallowing both of 
liquids and of solids ; further, the food before long begins to accumu- 
late above the seat of obstruction, and hence to be regurgitated after a 



DISEASES OF THE (ESOPIIAGUS. 



601 



longer or shorter period of time with a kind of gulp, an effort which 
has little or no resemblance to ordinary vomiting. The patient then, 
still probably retaining a good appetite, finds it necessary to restrict 
his diet to slops, and ere long finds that he can take even such food as 
this only in the smallest quantities, and with difficulty and distress. 
He then rapidly emaciates, and if no fatal complication ensue, dies after 
a shorter or longer period of suffering from simple starvation. Such 
deaths are usually exceedingly distressing, because the patient, as a 
rule, retains his mental powers unimpaired to the last, and because he 
craves for that nourishment which cannot be administered to him. 
These are the general symptoms of oesophageal obstructions ending 
fatally. The progress of such cases is usually, however, much modified 
by the nature of the diseases on which they depend. 

If the case be one of simple stricture from a cicatrix, its progress is 
generally greatly protracted ; and, although such cases are often ulti- 
mately fatal, instances are on record in which patients have lived, 
though with more or less discomfort, to a good old age, and have then 
died of some other ailment. It is in such cases especially that dilata- 
tion of the tube above the stricture takes place with compensatory 
hypertrophy, conditions which, confined within certain limits, tend to 
neutralize the effects of the stricture. 

If the case be one of malignant disease, this fact is often for awhile 
incapable of determination. The points which specially indicate it are 
the comparative rapidity with which the case goes on from bad to 
worse, the advanced age of the patient, the appearance of indurated 
glands in the neck, and the discharge from the oesophagus, in company 
with regurgitated food, of offensive, puriform, or sanious matter or 
detritus. Further, the sudden discharge of blood in large quantity, or 
the supervention of some communication between the oesophagus and 
the air-passages, strongly point to, although they do not absolutely 
prove, the presence of a malignant ulcer. 

The symptoms due to the pressure of external tumors differ but little 
from those arising from actual disease of the oesophageal walls; indeed 
these latter usually become after a time distinctly implicated. To aid 
our diagnosis we must carefully explore the neck and thorax in order 
to ascertain whether there be an enlarged thyroid body, a mediastinal 
growth, an aneurism, or any other form of tumor. But although in 
many such cases we may be enabled to form a correct diagnosis, in 
many all our efforts will necessarily be fruitless. 

We have stated that organic obstruction is usually of slow develop- 
ment ; it nevertheless occasionally arises with sudden completeness. 
In the case, for example, of obstruction from the compression exerted 
by a circle of effused blood around the cardiac orifice, the symptoms 
occur quite suddenly, and the patient dies probably of starvation at the 
end of ten days or a fortnight. 

An important point in reference to oesophageal obstruction is to 
ascertain its exact seat. It is important, partly in connection with the 
treatment to be adopted, partly as an element in determining the exact 
nature of the obstruction. The site of obstruction may be pretty cor- 
rectly determined in many cases by the sensations of the patient. It 



602 



DISEASES OF THE DIGESTIVE ORGANS. 



is often indicated to some extent by the phenomena which may be ob- 
served to follow the ingestion of a few mouthfuls of milk or other food ; 
thus, if the impediment be at quite the upper part of the tube, regurgi- 
tation immediately follows on the act of deglutition, and is probably 
attended with the intrusion of some of the fluid into the larynx ; if it 
be seated near the cardiac orifice its return may be delayed for some 
minutes or even longer. It is, however, on the passage of the bougie, 
and the determination of the exact point at which its progress becomes 
arrested, that our main reliance must be placed. Another useful 
method is that of auscultating the oesophagus. If the stethoscope be 
applied to the back in the course of this tube, and the person examined 
be made to swallow a mouthful of some fluid, its momentary passage 
in the form of a compact mass is distinctly audible. If, however, an 
impediment exist, especially if the impediment be considerable, there 
will be some obvious delay in the passage of the mass at its seat ; and, 
moreover, the mass, instead of passing in a compact form, will prob- 
ably trickle through in driblets, and its passage be attended with com- 
paratively prolonged gurgling. It is not sufficient, however, to deter- 
mine on one occasion, the existence of gurgling at a particular spot. 
We must ascertain, by repeated observation, whether that localized 
gurgling is permanent or not. 

Dilatation alone of the oesophagus is an impediment to the act of 
deglutition. The presence of dilatation, even if there be (as there 
usually is) muscular hypertrophy, necessarily renders the oesophagus 
a less efficient instrument for the propulsion of its contents. These, 
instead of being driven readily and rapidly onwards, accumulate in 
the flaccid bag, and thence find their way fitfully into the stomach. 
One of the most interesting phenomena connected with dilatation is the 
tendency which there often is for the accumulated contents of the tube 
to be regurgitated by an effort, more or less voluntary, into the mouth 
as in the act of rumination. 

Spasmodic stricture is apt to come and go more or less suddenly, 
and, if it be long-continued, to present intermissions or variations of 
severity. It is attended with many of the symptoms of organic stric- 
ture, and may even lead to death by starvation. The diagnosis rests 
partly on the patient's history and general state of health, partly on 
the variableness of the oesophageal obstruction, and partly on the evi- 
dence furnished by the unopposed passage of the bougie. 

The symptoms due to oesophageal paralysis are also mainly those of 
oesophageal obstruction. The food fails to be transmitted onwards to 
the stomach, and at the same time tends to accumulate in the tube and 
to distend it. The bougie passes without impediment. 

Treatment of Chronic (Esophageal Disease. 

The treatment of oesophageal obstruction is, in a very large propor- 
tion of cases, difficult and unsatisfactory. If the obstruction be func- 
tional only, the passage of a bougie will sometimes at once restore the 
capability of swallowing. The permanent cure, however, of such cases 
is to be obtained only by curing the nervous conditions on which the 



DISEASES OF STOMACH, INTESTINES, AND PERITONEUM. 603 



obstruction depends. If, on the other hand, the obstruction be organic, 
actual cure is probably out of the question ; the tendency indeed of the 
disease then is to render the occlusion of the tube more and more com- 
plete. We have no drugs which promote the absorption of cicatricial 
bands, or of carcinomatous or other tumors. We can, however, in 
some cases, by surgical means, check the progress of contraction, and 
indeed cause dilatation of a part already strictured. We have pointed 
out the importance, for diagnostic purposes, of passing an oesophageal 
bougie. The careful passage of a bougie through a stricture, and the 
repetition of the operation at intervals with instruments of gradually 
increasing size, will not only aid us in diagnosis, but in some cases 
relieve the stricture to a considerable extent, and maintain that relief. 
The passing of a bougie through an obstructed oesophagus is, how- 
ever, an operation of much delicacy, and attended with no inconsidera- 
ble danger, especially if the stricture consist of a tract of soft ulcerating 
cancerous material, or be due to the presence of a thoracic aneurism. 
The' bougie may in fact, under such circumstances, readily form a false 
passage, either into the trachea, the mediastinum, or the cavity of an 
aneurism, and so induce speedily fatal symptoms. So great is this 
danger that most practitioners regard this mode of treatment as almost 
entirely inadmissible ; and indeed it must, we think, be conceded that 
it is quite inadmissable in cases of compression of the oesophagus by an 
aneurism, and in cases of malignant disease — especially those in which 
ulceration or sloughing has taken place. But there cannot, we think, 
be a doubt of the benefit which may accrue from the regulated use of 
the bougie, in skilful hands, in cases of simple stricture. The dilator 
suggested by Dr. M. Mackenzie is well suited for such cases. The 
passage of the bougie has occasionally ruptured an abscess to which 
obstruction was due, and in this way cured the patient. When the 
ingestion of food is largely interfered with, and the patient shows 
manifest signs of starvation, the question as to whether there is any 
possibility of supplying him with food by any other route than the 
oesophagus arises. The use of nutritive enemata is one of the methods 
which suggest themselves, and is often useful in prolonging life. 
Another method is that of laying open the stomach itself through the 
anterior abdominal wall, and feeding the patient through the artificial 
opening. Several such operations have been performed, and although 
the cases have not been very successful, the feasibility of the operation 
has certainly been demonstrated. 



(3.) — DISEASES OF STOMACH, INTESTINES, AND 
PEKITONEUM. 

IOTKODUCTOKY KEMAEKS. 

Anatomical Relations. — The surface of the abdomen is artificially 
divided into regions which are convenient in the determination of the 
relations of the organs which are situated within. This division is 



604 



DISEASES OP THE DIGESTIVE ORGANS. 



usually effected by drawing two horizontal lines ; one above, from the 
lowest point to which the ribs descend on the one side to the corre- 
sponding point on the other side ; one below, between the anterior supe- 
rior spines of the iliac bones ; and then intersecting these by two vertical 
lines drawn, one on either side, from the cartilage of the eighth rib 
above to the centre of Poupart's ligament below. Nine unequal 
spaces are thus defined ; of which the three occupying the median 
aspect of the abdomen are, from above downwards, the epigastrium or 
scrobiculus cordis, the umbilical region, and the hypogastrium ; and the 
three on either side are, from above downwards, the hypochondriiun, 
the lumbar region, and the iliac region. The hypochondriac and iliac 
regions are small and triangular; the lumbar extend round to the 
spine, occupying on either side the whole interval between the ribs and 
the crest of the ilium, and are, therefore, of considerable extent. 

The epigastric region is mainly occupied by the stomach, inclusive 
of its pyloric extremity, portions of the right and left lobes of the liver 
appearing above on either side of the ensiform cartilage; more deeply 
seated lie the hepatic vessels, the pancreas, the coeliac axis and the 
semilunar ganglia. The umbilical and hypogastric regions are occupied 
almost exclusively b\ the convolutions of the small intestine; along 
the upper part passes the transverse colon, and into the lower part 
ascend the distended bladder and the gravid uterus. Deep in these 
regions lie the third portion of the duodenum above, and below the 
mesentery with its vessels and glands. The right hypochondriac region 
contains the lower edge of the right lobe of the liver with the gall- 
bladder, and the hepatic flexure of the colon ; more deeply the first and 
second portions of the duodenum ; and more deeply still the upper por- 
tion of the kidney and the suprarenal capsule. The left hyp>ochondrium 
is occupied by the lower portion of the spleen, the cardiac extremity 
of the stomach, the splenic flexure of the colon, and more deeply by 
the upper part of the left kidney and the suprarenal body. Each 
lumbar region is occupied by the convolutions of the small intestine, 
laterally by the ascending or descending portion of the colon, and 
further back by the lower half of one of the kidneys. In the right iliac 
region is placed the caecum, in the left the sigmoid flexure. 



GASTRITIS. 

Causation. — Acute gastritis in its severest form (except as the result 
of the direct application of irritant or corrosive substances to the mucous 
surface of the stomach) is exceedingly rare. Its milder varieties, on 
the other hand, are very common indeed, at all ages and in both sexes, 
and from their mildness not unfrequently escape recognition. The 
causes of gastritis are various, and include the ingestion of irritant or 
corrosive substances, the use of food which is ill-masticated, or too 
abundant, or unwholesome — excess, therefore, in eating and drinking, 
especially of alcoholic liquors — exposure to cold, and other atmospheric 



GASTRITIS. 



605 



influences. Among predisposing causes must be enumerated constitu- 
tional debility, tuberculosis, various acute febrile complaints, and the 
presence of heart disease, lung disease, renal disease, and cirrhosis of 
the liver. 

Morbid Anatomy. — Slight inflammatory conditions, though obvious 
enough when observed, as in the case of Alexis St. Martin, during life, 
often leave little trace of their existence after death. They are indi- 
cated by patchy congestion ; enlargement of the epithelial cells, with a 
more or less cloudy condition of their protoplasm, and the appearance 
within them of fat-granules ; similar changes in the cells of the raucous 
glands; and hypertrophy of the lymphatic tissue. These changes in- 
volve some degree of thickening and softening of the mucous membrane, 
and are attended with the formation of a greater or less abundance of 
ropy alkaline mucus, and diminished secretion of the true gastric juice. 
But these are not the only changes. Frequently, small extravasations 
of blood take place here and there into the substance of the mucous 
membrane, and small quantities of blood may escape even into the 
cavity of the stomach ; sometimes superficial ulcers or erosions form, 
and sometimes superficial sloughs. Some of these latter appear to be 
connected with, if not dependent on, previous hemorrhagic infiltration. 
When inflammation is clue to the action of corrosive substances, the 
morbid appearances are largely determined by their several peculiarities 
of chemical action. There is usually, however, intense congestion, with 
more or less extensive destruction of the mucous membrane. Inflam- 
mation involving the whole thickness of the walls of the stomach is 
rare as an idiopathic affection. In these cases the stomachal walls are 
swollen in their entire thickness, sometimes infiltrated with simple 
inflammatory exudation, or with pus, sometimes presenting scattered 
abscesses. 

The morbid anatomy of chronic inflammation differs little from that 
of the acute affection. There is generally, however, less congestion and 
more degeneration. The mucous membrane is usually thicker than 
normal, pale, and comparatively tough. It may present extravasations 
of blood, and excoriations or ulcers. But more frequently it is studded 
here and there with black or slate-colored spots which are the pigmental 
remains of old extravasations or congestions ; and with opaque white 
spots and patches which are due to fatty degeneration of the epithelial 
contents of groups of gland tubes, and even of the corpuscles of the 
connective tissue between them, and which are associated often with 
atrophy and shrivelling of the glands, and occasionally with a tendency 
to the formation of cysts. 

Symptoms and Progress. — 1. In severe idiopathic gastritis, as also in 
gastritis due to irritant poisoning, the symptoms are of an exceedingly 
aggravated character. The patient suffers from intense burning and 
shooting pain in the epigastrium, and lower part of the chest in front, 
and between the shoulders, attended with rigidity and retraction of the 
abdominal muscles ; pain and tenderness on pressure in the epigastric 
region j pain on drawing a deep breath, with consequent shallow respi- 
ration ; nausea, retching, and vomiting, not only after everything that 
is taken into the stomach, but even when the organ is empty ; total 



606 



DISEASES OF THE DIGESTIVE ORGANS. 



loss of appetite ; intense thirst • and collapse, marked by extreme feeble- 
ness of pulse, coldness and pallor of surface, cold perspirations, and 
tendency to faint. Besides these symptoms distressing hiccough usually 
soon supervenes, and the bowels may become loose. The nature of 
the matters vomited depends on circumstances. Generally, however, 
they comprise mucus (which is often mingled with more or less altered 
blood), bile, and necessarily the matters which have been swallowed. 
The supervention of collapse, which is so marked a phenomenon of the 
affection, is preceded by heat of skin and other febrile symptoms which, 
however, soon subside. When the case ends fatally, death is mostly 
due to prostration, and the patient usually retains consciousness to the 
last. The date at which death supervenes varies. If recovery take 
place, its course is usually protracted. 

2. In the more frequent and milder forms of acute gastritis, the 
symptoms which prove its existence are essentially the same as those 
which characterize the graver attacks, namely, heat or aching in the 
region of the stomach; tenderness on pressure in the epigastrium, with 
more or less rigidity of the abdominal muscles, more especially the 
recti, and the endeavor to obtain ease by bending the body forwards, 
and restraining the action of the diaphragm ; irritability of stomach, 
with tendency to eructation and to reject by vomiting whatever is taken 
into it; anorexia, thirst, and febrile disturbance. Besides which, the 
tongue is usually coated, and there is more or less headache, with in- 
tolerance of light, depression of spirits, and disturbed sleep. The 
symptoms are liable, however, to great variation, and even the most 
characteristic of them may in some cases be entirely absent. 

The pain in the stomach may be wholly wanting, or exist as a sen- 
sation of warmth only, or it may be replaced by a constant craving for 
food. The ingestion of food, however, in such cases does not usually 
give the anticipated relief, and often brings on pain and induces vomit- 
ing. The irritability of the stomach may be extreme; on the other 
hand, it may be indicated by frequent eructations only. Under any 
circumstances, however, the taking of food or drink, except in modera- 
tion, will probably insure its rejection and bring on epigastric pain. 
The vomit consists of ropy and tenacious mucus, mixed with matters 
which have been swallowed, and (if the vomiting have been prolonged) 
with bile. Blood, in small quantities, is occasionally contained in it. 
The breath is usually febrile or offensive, and not unfrequently abso- 
lutely fetid. The eructations occasionally have the odor of sulphuretted 
hydrogen. Thirst is generally a marked feature, but occasionally it is 
wholly absent. The temperature is usually elevated above the normal, 
but rarely exceeds 100° ; it presents variations during, the day, and, 
for the most part, an afternoon or evening exacerbation. The patient 
often feels chilly, and not unfrequently has distinct rigors. The skin 
is hot, but disposed to be moist. In the majority of cases the tongue 
becomes early covered with a thick whitish or brownish creamy fur, 
through which the congested fungiform papillse protrude ; but it may 
be abnormally red and clean, and then often dry and glazed; or it may 
be fissured. In some cases it is little changed from the normal. Taste 
is usually perverted; there is often a sensation of bitterness or a metallic 



GASTRITIS. 



607 



flavor. The headache is frequently very severe, of an aching or throb- 
bing character, and limited to some particular region. In some cases 
it is difficult, if not impossible, to distinguish it from that of migraine. 
It is when the headache is frontal that there are usually most marked 
disturbance of vision and photophobia. The patient is commonly more 
or less irritable, restless, yet depressed ; there is often considerable 
drowsiness, yet inability to obtain refreshing sleep, rest being disturbed 
by dreams. Further, the action of the heart frequently becomes en- 
feebled, the pulse quick and small, the extremities cold ; and there 
may be palpitation, faintness, dyspnoea, and confusion of mind. It 
must be added that, associated with gastric inflammation there is very 
often more or less disturbance of the bowels, generally flatulence, some- 
times constipation, sometimes griping and purging, sometimes irregu- 
larity of action. These disturbances are, however, in many cases due 
to concurrent inflammatory implication of the mucous membrane of the 
bowels. 

It will be gathered from the foregoing account that the milder 
forms of acute gastritis differ largely among themselves in the charac- 
ters which they present. In some cases, indeed, the symptoms scarcely 
differ from those of enteric fever; while in some they are little more 
than such as constitute an ordinary sick headache, and in others collect- 
ively amount to no more than that vague sense of illness to which the 
term " malaise' 7 is commonly applied. In young children, drowsiness 
and other cerebral phenomena, such as coma and convulsions, are not 
unfrequent accompaniments of the gastric disorder; and it is among 
them that diarrhoea is chiefly common. When gastritis arises in the 
course of other serious affections, its symptoms are peculiarly liable to 
be overlooked. 

3. The symptoms of chronic gastritis necessarily present a consider- 
able resemblance to those of the acute disorder; they are, however, on 
the whole more vague, and merge into those included in the collective 
term dyspepsia. The patient is, moreover, in many cases liable to 
remissions, during which he appears to enjoy comparatively good 
health, and to exacerbations, during which the symptoms of the affec- 
tion manifest themselves with more or less severity. In other cases the 
patient ails continuously. The febrile symptoms are, on the whole, 
slight, and are often altogether absent; the thirst, anorexia, vomiting, 
and uneasiness or pain in the epigastrium and between the shoulders, 
are all more variable and, on the whole, less severe than in the acute 
disorder; vomiting, however, of an abundance of glairy mucus is often 
a characteristic phenomenon; the tongue varies in its condition, as it 
does in the acute affection, and often becomes furrowed or intersected 
with Assure-like depressions; the breath is offensive; and the bowels 
are usually confined. The patient becomes irritable, nervous, restless, 
hypochondriacal, but rarely suffers so severely from headache as those 
who labor under the more acute disorder. With the continuance of 
the affection emaciation and debility come on, with defective circulation, 
coldness of the extremities, and a tendency to palpitation and faintness. 
Numberless other symptoms and consequences, of more or less impor- 
tance, are commonly, and no doubt in the main correctly, assigned to 



608 



DISEASES OF THE DIGESTIVE ORGANS. 



chronic gastritis. For the most part, however, they constitute no 
essential part of the disease, and are connected with it only as they are 
with many other affections in which the processes of nutrition are pro- 
foundly involved. 

Treatment. — 1. In the treatment of typical acute gastritis, local 
measures are of great importance. Leeches — twelve, twenty, or more — 
may be applied to the epigastrium ; or warm fomentations may be em- 
ployed, or ice, or mustard poultices and other counter-irritants. Which 
of these plans should be selected must depend on the severity, or stage, 
or other conditions affecting the case. The irritability of the stomach 
renders the introduction of food and of medicine in bulk into that 
organ impossible or undesirable. A little ice may be sucked, or ice- 
cold water or milk sipped ; and opiates in large doses should be ad- 
ministered. If given by the mouth they should be in the form of pill 
or powder, or of the solution of morphia, or of the undilute liquid extract 
of opium. The association of opium with bismuth or magnesia is 
often very efficacious. The best mode, however, of introducing opiates 
is undoubtedly by subcutaneous injection. 

2. In less severe cases, local bleeding need scarcely ever be resorted 
to, but warm fomentations and counter-irritants are of great benefit. 
Here also the use of ice, or of minute quantities of ice-cold water often 
affords much relief. And generally it is desirable to avoid as far as 
possible the administration of either food or drink until the irritability 
and pain have in great measure subsided. In some of these cases 
opium is of great value; generally, however, it is not called for. 
Bismuth, magnesia, lime-water, nitrate of silver, effervescent alkalies 
and hydrocyanic acid are often beneficial. When constipation is 
present, or when there is evidence of implication of the bowels in any 
way, purgatives are valuable, especially perhaps castor oil, calomel in 
combination with rhubarb, and enemata. When food is given it 
should be of light quality and easily digestible. Milk and farinaceous 
substances are most suitable. Later on, animal broths, fish, and 
chicken may be allowed. Alcoholic drinks are not desirable, unless 
there be marked tendency towards depression and collapse; under 
similar cirumstances ammonia is often serviceable. 

3. The chronic affection usually requires much attention to hygienic 
conditions. The patient should be enjoined to take moderate and regu- 
lated exercise, to seek change of air and scene, to keep good hours, and 
generally to adopt such a mode of life and such habits as are conducive 
to health. The diet should be strictly regulated, but it is difficult to 
lay down definite rules with respect to such regulation. The patient's 
own experience is usually an important, if not the best, guide. He 
should carefully avoid all those articles of diet which he has found to 
be prejudicial to him, however wholesome theoretically we may sup- 
pose them to be. Milk, well-cooked farinaceous substances, fish, fowl, 
and well-roasted mutton and beef in small quantities are probably on 
the whole the most suitable. Salted meats, rich and highly-seasoned 
dishes, pork and veal, should be especially eschewed. Tea often dis- 
agrees. Alcohol is occasionally beneficial, but it should only be used 
sparingly and in a dilute form. The particular beverage to be em- 



ENTERITIS. 



609 



ployed must depend on circumstances. As to medicinal treatment, the 
bowels should be regulated by occasional laxatives or mild purgatives : 
and tonics — especially quinine or dux vomica, in combination with 
hydrochloric acid, and calumba or gentian, associated with alkalies 
and rhubarb, or with bismuth — effervescing medicines, lime, silver, zinc, 
hydrocyanic acid, belladonna, opium, and pepsin, have all been found 
more or less useful under various circumstances and for different cases. 



ENTERITIS. 

1. Catarrhal Inflammation — Causation and Morbid Anatomy, — 
Acute inflammation of the bowels, like the corresponding affection of 
the stomach, presents many grades of severity. The simplest, or the 
catarrhal, form may be produced by the local action of irritating 
ingesta, or by the influence of those external conditions which set up 
inflammation in other parts. Young children, especially about the 
time of teething, are exceptionally liable to it; and it is said to be 
common in scarlatina and other specific fevers. It is characterized by 
congestion, tumefaction, and dryness of the mucous membrane, speedily 
followed by the secretion, often in abundance, of mucus, which is ropy 
or watery, irritating, and sometimes mixed with blood. 

Symptoms and, Progress. — Catarrh sometimes affects the lower bowel 
only, causing mild dysenteric symptoms; but very frequently it com- 
mences in the upper bowel, or in the stomach, and spreading thence 
downwards gradually traverses the whole length of the intestinal canal, 
causing in its progress more or less uneasiness, aching, and griping, 
frequently attended with nausea and sickness while it is still high up, 
with diarrhoea and expulsive pains and efforts when it reaches the large 
intestine. The tongue is generally more or less furred and dry, the 
breath offensive, and the appetite impaired ; but these symptoms vary, 
and are often absent, especially when the large intestine alone is affected. 
Some degree of general febrile disturbance, indicated by heat and dry- 
ness of skin with sense of chilliness, increased frequency of pulse, las- 
situde, and headache, is usually attendant on the local disorder. In 
children, in whom inflammatory affection of the gastro-intestinal 
mucous membrane is sometimes associated with aphtha, the disease not 
un frequently produces serious results and death, either from the debility 
which follows persistent diarrhoea and vomiting, or from the super- 
vention of cerebral complications, such as convulsions and coma. It is 
obvious that the symptoms of this disorder differ but little from those 
assigned to the commoner varieties of gastritis ; but gastritis and 
enteritis are usually associated in a more or less intimate manner, and 
their respective characteristics consequently intermingled. 

2. Pellicular Inflammation — Causation and Morbid Anatomy. — 
Inflammation with the formation of membranous pellicles in patches is 
not uncommon, especially in the large intestine. These pellicles con- 

39 



610 



DISEASES OF THE DIGESTIVE ORGANS. 



sist of corpuscular elements cemented together by a coagulable exuda- 
tion, and are prolonged for the most part by rootlets from their under 
surface into the Lieberkiihnian follicles. Their formation is usually 
attended with much greater congestion and thickening of the mucous 
membrane than is the simple catarrhal affection, and not ^infrequently 
there is haemorrhage, suppuration, or gangrene. In the large intestine 
the pellicular inflammatory patches are sometimes linear, sometimes 
irregularly polygonal or stellate ; and they occupy, for the most part, 
the prominent ridges of the mucous membrane, more especially the 
edges of the intersaccular constrictions ; in some cases, still occupying 
the more prominent parts, they form a coarse irregular network ex- 
tending over large tracts of surface ; in other cases they coalesce into 
uniform patches of considerable extent. In the small intestine pel- 
licular inflammation may be found affecting the free edges only of the 
valvulse conniventes or spread over large arese. It may be added that 
cases sometimes come under observation in which patients pass per 
anura shreds of false membrane, or even membranous casts of the 
bowel, of soft texture, various thickness, and a dirty greenish or 
brownish hue. This discharge is generally, if not always, the conse- 
quence of dysenteric ulceration. 

The symptoms which attend these morbid phenomena are not special; 
they vary, on the one hand, between those of diarrhoea and dysentery, 
and on the other hand between those of mere colic and of typical 
enteritis ; moreover the affection is often overlooked from the fact that 
it is apt to occur as a complication of the later stages of many grave 
disorders, as, for example, acute pneumonia, Bright's disease, cirrhosis 
of the liver, and cerebral affections. 

3. Chronic Inflammation — Causation and Morbid Anatomy. — These 
acute varieties of inflammation sometimes pass into the chronic condi- 
tion. But the chronic disease is frequently associated with morbid 
states of other organs, to which, indeed, it is often secondary. The 
stomach especially is apt to be the seat of some chronic morbid pro- 
cess. The mucous membrane becomes somewhat condensed and 
hardened, more or less congested, and studded with black pigmentary 
deposits. There is often some degree of atrophy of the follicles of 
Lieberkuhn, with granular or fatty degeneration of their epithelial 
contents ; and atrophy, or it may be enlargement of the solitary and 
agminated glands. 

The symptoms vary greatly, but may be briefly summarized as com- 
bining, in various proportions, imperfect digestion of the alimentary 
matters received into the intestine, excessive secretion of more or less 
watery mucus, increased peristalsis with griping pains, looseness of 
the bowels, discharge of watery, or yeasty, or otherwise unhealthy and 
offensive evacuations, and innutrition from the imperfect absorption of 
food. 

4. Phlegmonous Enteritis — Causation and Morbid Anatomy. — En- 
teritis par excellence, the phlegmonous enteritis of Cullen, is an affection 
of great severity and danger. It is not unfrequently met with, and 



ENTERITIS. 



611 



mainly as a consequence of some mechanical injury. Thus it may be 
an accompaniment of strangulated hernia or intussusception, or of the 
impaction of a gallstone or other foreign body, or of stricture. It is 
rarely of idiopathic origin. 

The morbid changes which may be looked for after death are such 
as are produced by intense inflammation of a limited tract of bowel. 
The affected part, which is mostly in the small intestine, and which 
may vary in length from an inch or two to one or two feet or more, is 
as a rule much dilated. Its serous surface presents a general dusky 
red, or slaty, or purplish black color, clue to the condition of the parts 
internal to it; it is marked, too, by lines or patches of more or less 
intense superficial congestion, may present blotches of subserous ex- 
travasation, and is often covered to a greater or less extent with 
adherent lymph. Its mucous and submucous tissues are mostly some- 
what thickened and softened, sometimes only moderately congested, 
but presenting spots and streaks of extravasation, sometimes black from 
combined congestion and escape of blood, sometimes pale and infil- 
trated with lymph or pus, sometimes distinctly gangrenous. And its 
middle coat, sharing in these changes, is also more or less swollen and 
soft, congested or oedematous, or the seat of some form of inflammatory 
exudation. The inflamed tract usually presents fairly well-defined 
limits, terminating abruptly below in pale and healthy but contracted 
and nearly empty bowel, above in bowel which may be also healthy, 
but is dilated like the diseased portion, and filled like it with fecal 
contents. The diseased intestine frequently contains, in addition to 
simple fecal matters, more or less sanguineous exudation ; and traces 
of the same may often be discovered in the contracted bowel below. 

Symptoms and Progress. — The symptoms of the form of enteritis 
now under consideration are, even when the disease is unattended with 
any of the mechanical lesions which so often complicate it, liable to 
considerable variety — the variations depending mainly on the degree 
of inflammation and its extent, and on the situation of the affected 
portion of bowel. The principal factors in producing its character- 
istic symptoms are inflammation, on w r hich depends the various febrile 
phenomena ; and paralysis of the inflamed portion of bowel, which per- 
mits of its passive dilatation by the accumulation of contents, opposes 
a more or less complete bar to their transit, and thus induces on the 
one hand constipation, on the other vomiting. 

Heat of skin, rigors, and quickness and hardness of pulse, not un- 
frequently mark the onset of the attack, but the invasion is in many 
cases insidious, and unattended with very obvious febrile symptoms. 
There is mostly some dryness and clamminess of the mouth, if not 
absolute thirst, and the tongue, which is occasionally pretty clean at 
the beginning, generally becomes soon thickly coated, and ultimately 
dry. 

A special feature of enteritis is the association of the abdominal 
pain and tenderness of peritonitis with the tormina of colic. Pain 
and tenderness are certainly present in most cases, at least in the be- 
ginning, and in dependence upon these the dorsal decubitus so char- 
acteristic of peritoneal inflammation. They are, however, sometimes 



612 



DISEASES OF THE DIGESTIVE ORGANS. 



scarcely appreciable from first to last, and generally subside in the 
progress of the case. It can readily be understood that, when the 
peritoneal surface is largely involved, pain and tenderness will gener- 
ally be proportionately severe ; that when an extensive length of bowel 
is affected, there will be correspondingly extensive uneasiness and ten- 
derness ; and that when, as sometimes happens, the serous surface is 
not inflamed, or when the affected portion of bowel is small, pain and 
tenderness may be not only limited in extent, but no greater than one 
finds them in colic or in simple ulceration of the mucous membrane. 
It may be observed that limited pain and tenderness are very com- 
monly referred to the region of the umbilicus. Tormina at the onset 
are often very agonizing, and are then probably due in some measure 
to the spasmodic movements of the inflamed bowel, but they continue 
after paralysis is established, in consequence of the violent but inef- 
fective efforts of the bowel above the seat of disease to overcome the 
impediment which the disease produces. But tormina are sometimes 
scarcely recognizable, and frequently, like pain, cease comparatively 
early. 

Constipation and vomiting are among the most essential symptoms 
of enteritis. Constipation, in the uncomplicated affection, is due sim- 
ply to want of contractile power in the inflamed length of gut. It is, 
therefore, not necessarily absolute ; there is no reason why the attack 
should commence with constipation, or why the bowel below the seat 
of disease should not empty itself in the progress of the case, or even 
why a certain amount of fecal matter should not slip through the 
inflamed portion of bowel into the healthier bowel below. Neverthe- 
less the inflamed bowel is really a substantial impediment, constipa- 
tion is a striking incident in the disease, and purgatives as a rule fail 
to produce a purgative influence. The vomiting of enteritis is prob- 
ably at the commencement mainly functional, but ultimately it is due, 
like the constipation, to intestinal obstruction. In the first instance, 
no matter where the obstruction, the vomited matters are merely the 
secretions of the stomach mixed with alimentary substances, but soon 
bile becomes mixed with these, and before long glairy mucus and bile 
alone are discharged. Then the eructations become fetid, and soon the 
fluid brought up gets turbid and brownish, and by degrees comes to 
resemble the contents of the lower part of the small intestine, but it 
becomes fetid also, far more fetid, indeed, than the contents of a healthy 
bowel ever are. This discharge of " stercoraceous " matter by the mouth 
is due, not to inverted peristaltic action, but to the fact that the gen- 
eral contents of the simply distended bowel become gradually churned 
up, as it were, and intermingled by the constantly recurring peristaltic 
movements of their muscular walls. 

Hiccough is often a distressing symptom. Tympanites is probably 
always present, slight at the beginning, but increasing as the case pro- 
gresses, until the belly becomes greatly distended, tense, and drum-like. 
It is mainly due to the distension of the inflamed bowel, and of the 
bowel above it, with fecal matter and flatus. But now and then it is 
connected with rupture of the distended intestine and escape of gas 
into the peritoneal cavity. 



ENTERITIS. 



613 



The pulse is usually accelerated and hard at the beginning, but it 
varies in different cases both in frequency, volume, and strength, and 
is sometimes nearly normal in character, but as the fatal issue ap- 
proaches it becomes more and more feeble, and sometimes at length 
wholly imperceptible at the wrist. It generally also becomes then 
quicker, but sometimes slower, and not unfrequently irregular. 

The temperature of the skin is usually in the first instance more or 
less elevated, and the surface dry, but even then perspirations are apt 
to break out, especially during the colicky paroxysms ; subsequently 
the temperature falls, the extremities and face become cold and pale or 
livid, with sometimes a slight tinge of jaundice, and all parts of the 
surface bathed in profuse cold perspiration. The expression of the 
patient is generally indicative of anxiety and distress, and his features 
are pinched and shrivelled. 

Pie generally retains his senses throughout his illness, and even 'up 
to the moment of death, but this event is often preceded by a period 
of quiescence or lethargy, and occasionally by slight rambling, and 
almost complete unconsciousness. There is generally almost complete 
suppression of urine. 

The disease now described is undoubtedly a very fatal and, indeed, 
very rapidly fatal malady. Death may occur within twenty-four 
hours, and is rarely delayed beyond a week. 

Treatment. — The treatment of the milder forms of enteritis is so in- 
timately connected on the one hand with that of inflammatory affections 
of the stomach, and on the other with that of diarrhoea and dysentery, 
that the reader may safely be referred to the articles on those subjects 
for all necessary details. As regards the treatment of the more severe 
forms of the disease, two main principles seem now to be fairly w r ell 
established. They are: first, to relieve pain, and prevent as far as 
may be, by means of opium, all movements of the bowels; second, to 
avoid every attempt (at least until all grave symptoms have ceased) to 
force the bowels by the administration of purgatives. Constipation, 
lasting for a few T days, or even prolonged for a week or two, is in itself 
a matter of very little consequence ; it is, however, a matter of very 
serious consequence to intensify the pain from which patients are 
already suffering, to fret and irritate inflamed organs, and to subject 
to unwonted violence a bowel unnaturally soft, enfeebled, and ready to 
undergo laceration. Clearly, if the patient is to get well, his recovery 
must in the first instance be dependent on the recovery by the diseased 
bowel of its healthy tone and capability of peristaltic action, and on 
the relief of pain and irritation. For these purposes, opium in large 
and frequent doses is generally our most valuable resource. No abso- 
lute rule can be laid down with regard to the quantity of this drug 
which should be given at one time, or to the frequency with which the 
dose should be repeated ; the patient, should, however, be got well 
under its influence, and kept under its influence. For many reasons 
it is best administered by subcutaneous injection. 

But our treatment need not be limited to the use of opium. The 
abstraction of blood is often of the greatest value. This is most efflca- 



614 



DISEASES OF THE DIGESTIVE ORGANS. 



cious earl) 7 in the disease, and may be effected either by the opening of 
a vein in the arm, or the application of ten, twenty, or thirty leeches 
to the surface of the belly. Warm but light applications, and hot 
fomentations generally soothe, and sometimes mustard plasters and 
similar mild counter-irritants give relief. In the same way enemata 
of warm water or gruel are at. times useful. To relieve nausea and 
vomiting, ice, hydrocyanic acid, alkalies, lime-water, bismuth, carmin- 
atives, and so on, may be tried, and may at first be of some efficacy ; 
but, when the vomiting is simply the consequence of over-distension 
of the bowels, as it is late in the disease, such remedies must neces- 
sarily fail. The extreme prostration which so early manifests itself 
is a strong indication of the need of food and stimulants; but their 
exhibition by the mouth tends to increase distension, already proba- 
bly painful, to promote sickness, and under such circumstances they 
are little likely to be absorbed. It is obvious, indeed, that alimen- 
tary matters, if given by the mouth, must be given in very small 
quantities, and in a form suitable for their ready appropriation by the 
system. They are, however, best administered in the form of enemata. 



ULCERATION OF THE STOMACH. 

Causation. — The occurrence of excoriation or superficial ulceration 
in the course of ordinary gastritis has been already referred to. Such 
lesions have rarely, however, any special importance, and as a rule 
speedily undergo spontaneous cure. But the stomach is also liable to 
become the seat of ulcers, which tend to spread widely and deeply, are 
productive of serious symptoms and sometimes of death, and the origin 
of which is to some extent enshrouded in mystery. These ulcers are 
rarely observed previous to the age of ten or fifteen, but subsequently 
to that period they seem to increase in frequency with advancing life, 
not, indeed, absolutely, but in relation to the numbers of persons living 
at each successive period. They appear to be two or three times more 
frequent in females than in males. They are often associated with 
amenorrhoea and anaemia, or chlorosis, and in both sexes (but more es- 
pecially in men) with the cachexia? which follow from habits of drink- 
ing and dissipation and from syphilis. It is possible, indeed, that 
these conditions of the system may be the actual causes of the ulcera- 
tion ; it is more probable, however, that they tend to promote the 
spread and to retard the healing of ulcers wmich have begun in the 
first instance independently of them. Yirchow considers that they 
originate mainly in affections of the vessels leading to the diseased 
area?, to embolism or degenerative change in the arteries, followed by 
obstruction and necrosis, or to obstruction of branches of the portal 
system of veins followed by interstitial haemorrhage. But it seems 
not improbable that the various superficial ulcers which form in gas- 
tritis, and which as a rule readily heal, may themselves, under certain 
circumstances, even if very rarely, remain open, and, remaining open, 



ULCERATION OF THE STOMACH. 



615 



be irritated into active enlargement. The progressive spread, and 
unwillingness to heal of gastric ulcers, are readily explained by the 
constant irritation to which they are subjected by the ingestion of 
food, the pouring out of gastric juice, and the motions of the stomach 
in digestion. 

Morbid Anatomy. — Gastric ulcers vary in size from that of a four- 
penny piece up to that of the palm of the hand. The smaller ones are 
usually circular or oval in shape ; the larger are more or less irregular, 
either from being formed by the coalescence of several smaller ulcers, 
or in consequence of their irregular extension. When small an ulcer 
usually appears as if it had been produced by the punching out of a 
portion of the internal parietes of the stomach. Its edges are more or 
less perpendicular; and the tissues entering into their formation are 
infiltrated and indurated to some little distance around, and probably 
also distinctly thickened. Its Moor may be smooth, flocculent, or even 
superficially gangrenous ; and may be formed, according to the depth 
to which the ulcer has reached, either by the submucous tissue, the 
muscular coat, or the serous membrane only. In an ulcer of large 
size the tissues which surround it are usually considerably thickened 
and indurated from inflammatory overgrowth, and often much con- 
gested ; the edges, which are themselves greatly thickened, usually 
slope downwards to the floor of the ulcer, which thus becomes smaller 
than the superficial area of ulceration ; sometimes, however, they are 
perpendicular; and sometimes they are undermined, and overhang. 
The floor of a large ulcer may be formed like that of a small one by 
any of the gastric tunics except the mucous membrane itself, but it 
may be formed also by the substance of the liver or pancreas, or by 
that of any other organ or tissue which has become adherent to the 
stomach at the seat of ulceration, and involved in the progress of the 
disease. The floor may be smooth, or irregular and flocculent, or in a 
sloughy condition, or it may present granulation-like bodies due to 
the projection of the lobules of the eroded pancreas. 

Gastric ulcers not unfrequently cicatrize. The surrounding thick- 
ening then diminishes, the sloping edges become indistinguishable on 
the one side from the contiguous mucous membrane, on the other from 
the floor of the ulcer. The ulcerated surface contracts, radiating puckers 
form, and the central raw area becomes smaller and smaller, and at 
length heals. The result is an opaque, whitish, smooth, tough, de- 
pressed area, surrounded by more or less obvious radiating folds of 
mucous membrane, and attended with more or less marked and it may 
be serious deformity of the stomach. It is not uncommon to find ulcers 
partly healed, or ulcers which are cicatrizing at one part, and under- 
going extension at another part. 

Unfortunately gastric ulcers do not always heal. In many cases 
they remain quiescent or slowly extend; in many they end in perfora- 
tion of the stomach; and then either the perforation takes place at once 
into the peritoneum ; or the base of the ulcer previous to its perforation 
becomes adherent to some neighboring solid viscus — the liver, pancreas, 
or spleen — so that extravasation of the contents of the stomach into the 
peritoneal cavity is prevented ; or a communication becomes established 



616 



DISEASES OE THE DIGESTIVE ORGANS. 



with the transverse colon, or small intestine, with the pleura through 
the diaphragm, or with the external air through the abdominal parietes. 
In other cases some artery, the splenic, the coronary, the gastro-epiploic, 
or one of their branches, or even the hepatic artery, or the portal vein, 
becomes eroded, and profuse haemorrhage ensues. 

Gastric ulcers are usually solitary, but occasionally two, three, or 
more are present at the same time. They may occur at any part of the 
gastric surface, but are more frequent in the pyloric than in the cardiac 
half ; more frequent in connection with the posterior than the anterior 
surface of the organ ; and more frequent in the neighborhood of the 
smaller than in that of the larger curvature. It may be pointed out 
that perforation is believed to be relatively more frequent in females 
than in males ; and that it is not an uncommon termination of the dis- 
ease in young women. 

Symptoms and Progress. — The symptoms which attend the presence 
of gastric ulcer present much variety. In a few cases the disease proves 
fatal by perforation or haemorrhage without having ever been attended 
with symptoms which have called attention to the stomach as the seat 
of disease. In the great majority of cases, however, the patient suffers 
from dyspeptic phenomena, of which the most common and character- 
istic are pain, vomiting, and hsematemesis. As ulcer of the stomach is 
mainly a chronic disease, so the symptoms to which it gives rise gener- 
ally assume a chronic character. They creep on for the most part 
gradually, sometimes probably intermitting for awhile, often present- 
ing exacerbations, but, on the whole, tending as a rule to become more 
and more aggravated. 

At first possibly the patient complains of distension, flatulence, and 
uneasiness, especially after food, and of impairment of appetite ; but 
soon the uneasiness becomes pain ; and sickness presently supervenes. 
The pain varies somewhat in intensity and in character. It usually 
commences in, and may be limited to, the epigastrium, which becomes 
tender on pressure ; or it is referred to the region of the spine corre- 
sponding to the last two or three dorsal and first two or three lumbar 
vertebra?, or to the interscapular region, the muscles on either side often 
being tender ; or it occupies the umbilicus, or some other point or area 
in the neighborhood of these several localities; and generally, when it 
is severe, it radiates from its point of chief intensity, upwards towards 
the oesophagus, backwards to the loins, or downwards and laterally 
over the greater part of the abdominal cavity. The pain, when severe, 
is of a burning or boring, or of a shooting character, with often a sense 
of soreness; it is usually aggravated by taking food, and in some cases 
occurs only at these times. It usually comes on a few minutes after 
ingestion, but is occasionally delayed until half an hour or an hour 
afterwards. It is doubtful how far the situation of the pain serves to 
indicate the situation of the ulcer; but both Dr. Budd and Dr. Brinton 
are inclined to believe that pain occurring chiefly in the pit of the 
stomach indicates the presence of an ulcer in the anterior wall of the 
stomach, that pain in the back implies a corresponding situation for 
the ulcer, and so on. Further, Dr. Brinton regards the decubitus of 
the patient as suggestive in this respect, the patient lying as a rule on 



ULCERATION OF THE STOMACH. 



617 



that aspect of the body which is farthest removed from the seat of the 
ulcer. 

Vomiting maybe absent from first to last; it usually comes on, how- 
ever, during the progress of the case, for the most part subsequently to 
the pain, and is then very persistent. The attacks are determined by 
the taking of food, usually come on a little later than the pain, and not 
1111 frequently by emptying the stomach cause the pain to subside. The 
vomiting may be attended with violent spasmodic efforts, or may be 
effected in the manner of simple regurgitation. Haemorrhage is a fre- 
quent consequence of gastric ulcer, taking place sometimes from the 
congested mucous membrane which bounds it, sometimes from the gen- 
eral surface of the ulcer, sometimes from a comparatively large vessel 
which has undergone erosion. In the last case especially haemorrhage 
is apt to be very profuse, and to be repeated from time to time; and 
large quantities of blood consequently are vomited and subsequently 
passed by stool. 

The long continuance of dyspeptic symptoms, with pain induced by 
taking food and having the characters which have been described, and 
with vomiting coming on pretty constantly at some variable period 
after ingestion, are alone strong presumptive evidence of the presence 
of a gastric ulcer. And if to these symptoms be added the occurrence 
of profuse haematemesis there can be little room for doubt. 

The most frequent termination of gastric ulcer is no doubt in conva- 
lescence. There is, howevever, a great tendency for healed ulcers to 
break out again, and consequently for patients who seem to have recov- 
ered to have relapses. When the disease ends fatally, death may be 
due to simple asthenia — the patient sinking, worn out by the combina- 
tion of long-continued pain, vomiting, and want of food ; or it may be 
caused by the sudden loss of a large quantity of blood, or by the repe- 
tition, at longer or shorter intervals, of smaller but still copious haemor- 
rhages ; or it may be the consequence of perforation. When perforation 
takes place into the peritoneal cavity, sudden intense abdominal pain 
and collapse occur, speedily followed by general peritonitis ; and the 
patient usually dies in from five or six hours to two or three days after 
the occurrence of the accident. When, however, perforation takes 
place into any of the hollow viscera or other cavities than that of the 
peritoneum, the symptoms which arise are usually much less sudden 
and grave, though still in many cases leading sooner or later to a fatal 
result. 

Treatment. — Attention to diet is of the utmost importance in the 
treatment of gastric ulcer. The patient must be nourished, and yet all 
the digestive actions of the stomach are inimical to the cure of the 
lesion. We must consequently be especially careful as far as possible 
to avoid overloading the stomach or causing gastric pain or uneasiness, 
or vomiting. With this object it is important to administer as little 
food as is compatible with the maintenance of life, to give it in small 
quantities at a time, and at short intervals; it is important also to select 
food of such a kind as will impart nourishment without causing undue 
irritation of the stomach ; and, in reference to this matter, it may be 
observed that few articles of diet are so suitable as milk, which may be 



618 DISEASES OF THE DIGESTIVE ORGANS. 

thickened, if necessary, with biscuit powder, arrowroot, or similar sub- 
stances. Milk, however, sometimes disagrees, and then recourse must 
be had either to farinaceous substances mixed with water, or to animal 
broths and jellies. Liquids are generally ill borne when hot ; and 
hence it is usually best to administer them tepid or cold. Hot tea and 
coffee especially are injurious. As the case progresses towards recovery 
eggs may be given, and tender, easily digested meats. Alcoholic stim- 
ulants should as far as possible be avoided ; if given, they should be in 
a dilute form and cold. In some cases it is necessary to feed the 
patient for a time by means of nutrient enemata only. The chief me- 
dicinal agents which have been employed for the cure of ulcers are 
nitrate of silver, bismuth, the carbonated alkalies, and opium. It is 
certain that the combination of bismuth, in doses varying from ten to 
twenty grains, with opium, is often very efficacious in relieving pain 
and vomiting and apparently in promoting the cure of the ulcer. Iron 
and the vegetable tonics are indicated when the more distressing symp- 
toms have been relieved and the patient seems convalescent. When 
haemorrhage occurs he should be kept quiet in the supine posture, ice 
should be given him to suck, and astringent medicines exhibited, 
among the more important of which are tannic acid, acetate of lead, 
perchloride of iron, and turpentine; and ice-bags should be applied to 
the region of the stomach. * 

Counter-irritation and other external treatment applied to the epi- 
gastrium are often serviceable. 



ULCERATION OF THE BOWELS. 

Causation and Morbid Anatomy. — 1. Intestinal ulcers are much 
more common and much more various in character than are those of 
the stomach. Their causes, however, are for the most part equally 
difficult of recognition. In many cases, no doubt, simple inflammation 
of the mucous membrane is followed by excoriation, which either 
rapidly heals and thus becomes obliterated, or, in consequence of ex- 
posure to constant irritation, becomes a veritable ulcer. Such ulcers 
may be a consequence of mechanical irritation. They are roundish, or 
somewhat irregular in form, vary in size, present more or less con- 
gested and well-defined margins, and irregularly excavated shreddy 
grayish surfaces. The margins and the surrounding tissues are in some 
cases considerably thickened and indurated, in other cases present little 
obvious departure from the normal state. Such ulcers are not unfre- 
quently met with in the duodenum, and are then in many cases not 
improbably due to the same causes (whatever they may be) as the so- 
called "chronic ulcers" of the stomach. They are occasionally also 
met with here apparently as the result of extensive superficial burns of 
the skin ; and are occasionally associated with the passage of gall- 
stones from the gall-bladder into the bowel. The large intestine, how- 
ever, is probably by far their most common seat ; and they are pro- 



ULCERATION OF THE BOWELS. 



619 



duced here for the most part by the mechanical irritation of retained 
faeces or intestinal concretions. They are not uncommon in the caecum 
and its appendage, where such accumulations are very apt to form ; but 
they may be developed at any part of the larger bowel. In cases of 
long retention of faeces, whether from simple constipation or from stric- 
ture, it is not rare to find the mucous surface studded with tracts, vary- 
ing from one to many square inches in area, consisting of groups of cir- 
cular ulcers of the kind now under consideration, from half an inch 
downwards in diameter, and separated from one another by a network 
of congested and partly undermined bands of mucous membrane. It 
must not be forgotten, however, that such ulcers may arise in any part 
of the intestine, large or small, from the effects of the passage or im- 
paction of gallstones or other concretions, and more especially when 
such impaction occurs above the seat of a stricture or other form of 
obstruction. 

2. In other cases ulceration commences with the formation of a mem- 
branous pellicle; a linear or stellate, or irregularly polygonal patch of 
mucous membrane becomes congested and swollen, and soon covered 
with an opaque whitish or buff-colored exudation, which is friable and 
granular on the surface, and extends by rootlets into the Lieberkuhnian 
follicles. This, after a time, separates, leaving sometimes a sound sur- 
face, sometimes a slight excoriation or even a distinct ulcer, with a 
somewhat cupped grayish or yellowish floor and a well-marked margin 
of congestion. Ulcers originating thus may be met with in any part 
of the bowels, but are much more common in the large intestine than 
elsewhere. In the small intestine they chiefly affect the free edges of 
the valvulae conniventes ; and in the large, either the projecting ridges 
formed by the intervals between the sacculi, or those corresponding to 
the longitudinal muscular bands. Sometimes we find extensive tracts 
of congested bowel studded or intersected with patches or bands of 
either membranous exudation or consecutive ulceration, or both inter- 
mingled. This affection is met with under various circumstances ; in 
pneumonia, and in *many forms of chronic disease, such as Bright's 
disease, cirrhosis of the liver, cancer, and chronic phthisis. 

3. Sometimes ulcers originate in patches of submucous suppuration, 
as we occasionally see in pyaemia, or in patches of deepseated sloughing 
like ordinary boils. Among these latter may perhaps be reckoned the 
ulcerative inflammation of the follicles of the colon, which Rokitansky 
describes, and are considered by many to be the early stage of dysen- 
tery. The follicles enlarge to the size of a tare or a pea, become sur- 
rounded by a halo of congestion, and then undergoing suppuration, 
form each an ulcerated opening, which eventually enlarges and forms a 
circular ulcer, with overlapping edges. 

4. In other cases again ulceration is produced by the formation and 
separation of a superficial slough. Circumscribed patches of intense 
congestion or extravasation appear in the substance of the mucous 
membrane, which, shortly dying, come away bit by bit, or in mass. 
The formation and separation of such patches are often effected with 
little obvious change in the parts immediately surrounding them, and 
the resulting pits become for the most part speedily effaced. This affec- 



620 



DISEASES OF THE DIGESTIVE ORGANS. 



tion is not uncommon in small-pox, typhus, and other such diseases. 
It very frequently involves only the valvular conniventes, or the cor- 
responding projections of the large intestine. It may be due to sudden 
arterial obstruction. 

5. But sloughing, to a much more serious extent, is sometimes met 
with, especially in the large intestine ; patches of mucous membrane 
become livid, or brown, or nearly black with congestion, and then their 
central arese assume a gray or ashy color, get shrunken, depressed, and 
softened, and soon break down into a soft, shreddy substance ; this 
partly becomes detached and partly adheres to the floor of the excava- 
tion and to its not yet broken-down edges, which latter tend to spread 
and to involve more and more of the surrounding tissues. 

It is not pretended that all non-specific ulcers arise in one or other 
of the modes here enumerated, or that these several varieties of ulcer 
are even in the beginning in all cases essentially distinct from one 
another. Still less do they necessarily maintain such distinctions in 
the later stages of their progress. Fully-formed ulcers indeed present 
considerable variety of appearance, dependent mainly on the processes 
which are actually taking place in them. Thus when they are healing, 
we find the general surface smooth and clean, or granulating, the edges 
little thickened or congested, perhaps puckered, and probably sloping 
more or less obviously to the surface of the ulcer with which they are 
in fact continuous; when they are sluggish, the edges are more or less 
tumid and rounded, and probably overhanging, and the general surface 
smooth ; when they are spreading, the surrounding mucous membrane 
presents more or less intense congestion and swelling, and the imme- 
diate edge is either flocculent and ash-colored, or presents a vivid red, 
raw, bleeding wall, or forms a more or less complete rim of distinct 
gangrene, and the floor is irregular and flocculent. The base of an 
intestinal ulcer is generally constituted by the submucous tissue, but 
not unfrequently the transverse muscular fibres are exposed ; and when 
an ulcer tends to perforate the bowel the muscular coat itself becomes 
opaque, softened, and in part destroyed. 

The above account applies mainly to individual ulcers. But very 
frequently, and much more frequently in the large than in the small 
intestine, many ulcers are present at the same time, and tend to in- 
crease either in number or size or in both of these respects, and to 
coalesce in a greater or less degree; and then, according to the stage 
to which the lesion has advanced, we meet in different cases with either 
a number of ulcers separated one from another by an imperfect network 
of mucous membrane, or interlacing networks of ulceration and of 
mucous membrane, or islets of mucous membrane in an expanse of 
ulceration, or, lastly, extensive tracts from which the mucous coat has 
been wholly removed. In these cases the transverse muscular fibres 
are often freely exposed, and the remains of mucous membrane are red 
and swollen and rounded, forming tubercle-like excrescences. The 
bowel, moreover, is frequently much contracted, and the muscular walls 
hypertrophied. 

This is not the place to discuss the important subject of specific 
ulceration of the bowels. It may, however, be pointed out that spe- 



ULCERATION OF THE BOWELS. 



621 



cific ulcers constitute by far the most formidable class of intestinal 
ulcers. The more important of them are the following : First, syphil- 
itic ulcers : these have not been certainly recognized in the alimentary 
canal except in the neighborhood of its inlet and outlet. Syphilitic 
ulceration of the rectum is a well-recognized, and for the most part 
very intractable, lesion. Second, the ulcers of enteric fever: these 
mainly affect Peyer's patches, and are most abundant and large in the 
lower part of the ileum ; they not unfrequently involve also the solitary 
glands of the large intestine, especially in its upper part. Third, 
tubercular ulcers, which originate for the most part in the same glands 
and in the same situations as enteric-fever ulcers. And, fourth, the 
various forms of ulcer due to the breaking down of carcinoma and 
other varieties of malignant disease. 

Many intestinal ulcers cicatrize and leave behind them little or no 
trace of their existence. In other cases, however, and indeed in a large 
proportion of them, results of more or less serious importance follow. 
Sometimes, as we see in the rectum, when a vast continuous surface 
has been destroyed, the wound never heals; and, even in cases where 
the destruction has been much more limited, the ulcer may assume the 
characters so often presented by chronic ulcer of the stomach, and be 
ready, if it cicatrizes, to break out again and again. But generally, 
when a large ulcer heals wholly or in part, some degree of contraction 
of the calibre of the bowel is the consequence. Stricture, indeed, 
often follows cicatrization, especially if the ulceration has involved the 
whole circumference of the bowel. In many cases haemorrhage takes 
place either from the congested surfaces or margins of ulcers, or from 
vessels perforated in their progress. And such haemorrhage may be 
so frequently repeated, or so abundant, as to prove fatal. In many 
cases, also, perforation of the bowel takes place at the seat of ulceration. 
This accident is usually due to a sudden tear in the floor of an ulcer, 
which has become unusually thin, and undergone softening, or become 
in some other way weakened ; and it not unfrequently depends imme- 
diately on some violence inflicted from without, or on some undue 
pressure from within, such as may result from overdistension of the 
bowel, or violent peristaltic movement. The rupture usually takes 
place at once into the peritoneal cavity, causing extravasation of fecal 
matter and generally fatal peritonitis ; but not unfrequently inflamma- 
tion arises on the peritoneal aspect of the bowel, which is threatening 
to become perforated ; adhesion takes place between it and some neigh- 
boring viscus ; and the threatened perforation becomes consequently, 
for a time at least, averted. In a considerable number of cases, per- 
foration of the bowel leads to the establishment of a communication 
between that viscus and some neighboring hollow organ, or even the 
surface of the skin. Not unfrequently this communication is pre- 
ceded, as pointed out, by the formation of adhesions ; sometimes it is 
connected with the development of a circumscribed abscess between 
the two organs — a mode of communication which is especially liable to 
take place when the ulcer opens on the mesenteric aspect of the small 
intestine, or on the corresponding aspect of the larger bowel, and con- 
sequently into the connective tissue, with which the bowel is in these 



622 



DISEASES OF THE DIGESTIVE ORGANS. 



situations closely invested. Thus, we occasionally find contiguous 
portions of the small intestine opening into one another, or the small 
intestine into the transverse or some other part of the colon ; the rec- 
tum or sigmoid flexure or the ileum communicating with an ovarian 
cyst, the urinary bladder, or the vagina ; the duodenum and perhaps 
the transverse colon with the gall-bladder ; the stomach with the trans- 
verse colon ; or, again, almost any part of the intestinal canal with the 
external surface. 

Symptoms and Progress. — The symptoms of ulceration of the bowels 
are so constantly associated with those of the various morbid states of 
the system on which the ulceration depends, or with those due to the 
various complications which follow upon ulceration, that we have sel- 
dom the opportunity of studying them in their simple form. It may 
be stated generally that ulceration of the bowels is often attended with 
more or less obvious febrile symptoms, which assume, if the disease 
become chronic, a distinctly hectic character ; that the affected bowel 
is often more or less tender on pressure — a characteristic which is 
especially observable if the ulceration be extensive, or if it occupy the 
csecum or some other part of the large intestine ; that there is almost 
necessarily some impairment of nutrition marked by emaciation and 
debility with feebleness of circulation ; that there is more or less ab- 
dominal soreness or aching or griping; and that, above all, there is 
something abnormal in the action of the bowels and in the evacuations. 
The symptoms will be modified according to the seat of ulceration. If 
the ulcer be high up, especially if it be in the duodenum, the symp- 
toms will approximate to those of gastric ulcer; there will probably 
be pain coming on some time after food, and vomiting, but no material 
interference with the function of defecation. If the ulceration be 
situated in the central portion of the small intestine, there may be 
nothing beyond gradually increasing emaciation, and occasional colicky 
pains to indicate that the bowels are affected; and indeed extensive 
ulceration may be present even in the lower part of the ileum without 
occasioning any obvious disturbance of the bowels; there may, indeed, 
be constipation from first to last. Usually, however, if there be ulcer- 
ation of the lower part of the ileum, and especially if there be ulceration 
of the large intestine, more or less diarrhoea may be looked for. The 
stools are then generally liquid, and contain an abnormal quantity of 
the fluid secretions of the bowels, and not unfrequently more or less 
blood ; they are, moreover, often peasoup-like in color and consistence, 
and more fetid than in health ; further, they are usually passed much 
more frequently than natural, and the patient suffers from frequent 
colicky pains and tenesmus. As the ulceration approaches nearer and 
nearer to the lower part of the large intestine, the evacuations assume 
more and more of the so-called " dysenteric" character. They are 
then passed with extreme frequency and with great tenesmus; are 
scanty, mucous, and often sanguinolent, and not unfrequently en- 
tirely free from true fecal matter, which latter may be passed occa- 
sionally only in small hard lumps, invested in the mucus which the 
diseased bowel yields. Constipation in fact, so far as regards the pas- 
sage of fecal matter, is often one of the most troublesome and distress- 



ULCERATION OF THE BOWELS. 



623 



ing symptoms of ulceration of the lower part of the large intestine. It 
is in the dysenteric form of the disease, moreover, that the evacuations 
become most offensive, the fetor being sometimes putrid and almost 
insufferable. Besides the slight oozing of blood which tinges the evac- 
uations in dysenteric diarrhoea, hemorrhage to a considerable amount 
sometimes takes place; and this may be either continuous or recurrent, 
and sufficient to destroy life. Many of the communications which 
have been described as taking place between the intestine and other 
organs as a result of ulceration are doubtless of little practical impor- 
tance ; some, however, are dangerous, or present features of special 
interest. Among these latter may be especially mentioned communi- 
cations between the stomach or duodenum and the colon, which lead 
to the occasional or constant vomiting of actual fseces and to the escape 
of undigested food into the large intestine; and communications with 
the urinary bladder, which occasion the escape of flatus and of faeces 
into that viscus, with other consequences which are easy to foresee. 
Rupture into the peritoneum generally causes fatal peritonitis. 

Treatment. — Our aims in treating ulcers of the boweis should be, first, 
to promote the healing of the ulcers and to prevent as far as possible 
the local mischances which are apt to follow; second, to check abdominal 
discomfort and diarrhoea; and, third, to support the patient's strength. 
It is, of course, doubtful how far remedies given by the mouth can 
act locally on ulcers low down in the bowels, and how far, therefore, 
remedies like bismuth, nitrate of silver, iron, copper, the mineral acids, 
and the like can promote cicatrization ; still they are often employed 
with this object, and sometimes apparently with benefit. It is, how- 
ever, of great importance that the bowels should be kept at rest, and 
that violent peristaltic movement should be as far as possible restrained. 
Purgative medicines, therefore, on the one hand, should be entirely, or 
in great measure, eschewed ; and on the other various astringent medi- 
cines — lime, tannic acid, chalk, or vegetable astringents — may prove 
serviceable. Opium is especially valuable, and the compound kino 
powder and the combination of aromatic chalk powder with opium are 
useful compounds. It is important, however, to note that opium cannot 
always be taken in these cases; for chronic ulceration of the bowels is 
often attended with an irritable state of the mucous membrane of the 
mouth and stomach which the use of opium is apt to augment. If this 
drug cannot be employed, it may be replaced, to some extent, by other 
sedatives, such as hyoscyamus, belladonna, Indian hemp, or hydro- 
cyanic acid. Opium may often be given with advantage in the form of 
enema or suppository. It is obvious that the various measures which 
have just been enumerated, while they check peristalsis, act with equal 
efficacy in fulfilling the second indication of treatment, namely, the 
arrest of diarrhoea. The maintenance of the patient's strength must be 
effected by the exhibition of tonic medicines and the careful adminis- 
tration of food and stimulants. The form of tonic must be adapted to 
the special requirements of the case and to the other details of treat- 
ment it may be considered necessary to adopt. As regards food, this 
should be well cooked, well masticated, easy of digestion, given in 
moderate quantities, and at regular, if not frequent, intervals. Fari- 



624 



DISEASES OF THE DIGESTIVE ORGANS. 



naceous foods are in many cases most suitable, but eggs, -fish, and fowl 
may often be used with advantage. Butcher's meat is sometimes 
wholly inadmissible. 

[Duodenal Ulcers. — Recent investigations seem to show that ulcers of 
the duodenum are of much more frequent occurrence aud importance 
than had been previously thought. Thus, according to Niemeyer, duo- 
denal ulcers or their cicatrices were found by Willigk in one thousand 
post-mortem examinations seventy-six times ; in two cases the ulcers 
being perforating. They are usually situated in the upper horizontal 
portion of the gut, but have been found in the descending and lower 
horizontal portion. The disease affects men oftener than women, is 
more common after middle age, and is rare in childhood. The ulcer 
resembles the gastric ulcer closely in appearance, and is believed to 
depend upon the same cause — thrombosis of a small vessel and subse- 
quent necrosis of the mucous membrane supplied by it. Sometimes 
the ulcer in cicatrizing causes stricture of the duodenum, at other times 
obliteration of the ductus choledochus. 

The symptoms of duodenal ulcers are generally very obscure, differ- 
ing little, if at all, from those caused by gastric ulcers. In most cases 
their existence is unsuspected during the lifetime of the patient ; in 
other cases attention is only awakened to the possibility of their pres- 
ence by the occurrence of vomiting of blood, followed by suppression 
of the urine and collapse, and, if he survives long enough, by peri- 
tonitis. They have occasionally, however, given rise to dyspeptic 
symptoms and to pain, referred by the sufferer to the region occupied 
by the duodenum, and coming on some hours after meals. Vomiting 
is less frequent than in gastric ulcers, but it is sometimes observed. 
Icterus too may be present, but not so often as we should expect from 
the duodenum being the seat of the disease. 

The treatment to be pursued is essentially the same as that recom- 
mended for gastric ulcers. Niemeyer speaks favorably of the use of 
alkaline and alkaline-saline mineral waters. The diet should be care- 
fully regulated.] 



PERFORATING ULCERS OF THE C^CUM AND RECTUM. 

{Typhlitis, Perityphlitis, and Periproctitis.) 

There are certain parts of the bowels which are especially liable to 
become the seat of non-specific forms of inflammation and ulceration, 
or to be involved in inflammation originating or existing in their neigh- 
borhood : these are the duodenum and the large intestine, or more par- 
ticularly the caecum and lower part of the rectum. 

As to the duodenum, we have already pointed out that it is not un- 
frequently the seat of ulcers which seem to resemble chronic ulcers of 
the stomach, and that ulcers are apt to arise there in connection with 
extensive burns of the skin. We may add that from its situation and 
attachments it is liable to become perforated from without by abscesses 



TYPHLITIS — PERITYPHLITIS. 



625 



of the gall-bladder, by hepatic abscesses, and by abscesses originating, 
no matter how, in the upper part of the retroperitoneal tissue. 

So, also, the large intestine, from its peculiar relations with the 
peritoneum, from the extent to which it is in many places devoid of 
peritoneal covering, and continuous, therefore, with the subperitoneal 
connective tissue, and thus brought into almost immediate connection 
with the various organs lying beneath the parietal peritoneum, is pe- 
culiarly apt to be involved in extraneous inflammation and suppura- 
tion. For similar reasons (at least in great measure) inflammation 
originating here is specially apt to induce inflammatory thickening 
and abscess in the surrounding tissues. 

Typhlitis. Perityphlitis. 

Causation and Morbid Anatomy. — The terms typhlitis and perityph- 
litis (the former signifying inflammation of the walls of the caecum, the 
latter inflammation of the tissues surrounding the caecum) are com- 
monly employed in reference to those cases in which inflammation of 
the caecum or its vermiform appendage involves, either by perforation 
or simple extension, the connective tissue of the iliac fossa or the peri- 
toneal cavity. Ulceration of these parts no doubt very frequently takes 
place (in enteric fever and in phthisis to wit) without causing the spe- 
cial phenomena of typhlitis. There is reason to believe, indeed, that 
in nearly all, if not in all, cases where inflammation spreads from the 
caecum to the surrounding tissues, the spread is referable to ulcerative 
perforation. The causes of this lesion are no doubt various. It may 
be due to the extension of tubercular, or typhoid, or dysenteric ulcers, 
to simple but extreme distension of the caecum, to the fretting of its 
surface by accumulated fecal contents, to the mechanical effects of 
bristles, pins, or bits of bone which have been accidentally swallowed, 
or to the lodgment of intestinal concretions. Concretions varying from 
the size of a pea to that of a date-stone, which are sometimes of a waxy 
consistence and lustre, sometimes brown, opaque, laminated, and for 
the most part fecal, sometimes composed mainly of earthy phosphates, 
but which all consist in an admixture in unequal proportions of ordi- 
nary fecal matters and the secretions from the mucous surface, and 
which have occasionally become developed around some small extra- 
neous body, are mostly found in the vermiform appendage and are the 
usual causes of perforative ulceration of that organ. 

In some cases the ulcer perforates that portion of the bowel which is 
devoid of peritoneal covering. Fecal matter then escapes into the 
surrounding tissues, leading to more or less extensive inflammation and 
induration, and probably also to the formation of an abscess. If the 
escape be but small in quantity inflammatory swelling may alone take 
place, and after a while subside. Often, however, an abscess forms 
which pretty rapidly enlarges, and in enlarging takes a course depend- 
ent more or less on its original position ; in one case descending into 
the pelvis and opening perhaps into the rectum, in another passing out 
with the pyriformis muscle and presenting in or below the buttock, in 
another forming a swelling in the groin immediately above Poupart's 

40 



626 



DISEASES OF THE DIGESTIVE ORGANS. 



ligament, or passing along the inguinal canal towards the scrotum, or 
along the psoas and iliacus muscles into the upper part of the thigh. 
In the great majority of cases no doubt it presents itself in the iliac 
region superficial to the position which the caecum normally occupies. 
An abscess of this kind may become cured by discharging its contents 
either through the orifice in the caecum which gave rise to it or through 
an opening at any one of the spots which have been enumerated ; or, 
burrowing extensively, it may form a sinus or a series of sinuses which 
never become obliterated. The communication between the abscess 
and the caecum is sometimes maintained, at other times is more or less 
speedily closed. In some cases (especially if the part affected be the 
vermiform process), 'circumscribed peritonitis precedes or accompanies 
the perforation, which would otherwise have been direct into the gen- 
eral peritoneal cavity ; and a circumscribed abscess forms, the indica- 
tions and progress of which will differ little, if at all, from those of 
the abscesses previously considered. In other cases perforation takes 
place directly into the peritoneal cavity and fatal peritonitis is excited. 
It may be - added that the circumscribed abscesses may themselves rup- 
ture ultimately into the cavity of the peritoneum. 

The most frequent form of fatal typhlitis is no doubt that which 
results from perforation of the vermiform appendix, an accident which 
occurs mainly in early life, and apparently more frequently in males 
than in females. 

Symptoms and Progress. — The symptoms of typhlitis are, in the first 
instance, pain, tenderness, and swelling in the region of the caecum, 
together with signs of inflammatory fever, and sometimes rigors. The 
local symptoms, indeed, are for the most part those which might be 
caused by inflammation of whatever origin occupying the venter of the 
ileum. If an abscess forms, but extends downwards into the pelvis, 
or remains deepseated, the case is naturally obscure. If, however, it 
tends to point anteriorly, the fulness and hardness become more and 
more pronounced, and gradually develop into a fluctuating hemispher- 
ical protuberance over which the integuments become oedematous and 
congested. Sometimes, even at this stage, the swelling gradually sub- 
sides and disappears, owing to the abscess having discharged itself into 
the bowel ; but more frequently it still enlarges and ultimately opens 
externally, discharging a greater or less amount of fetid pus, sometimes 
having a fecal odor, sometimes containing fecal matter and bubbles of 
gas. The further progress of the case may be towards either more or 
less speedy recovery, or the formation of successive abscesses or of fis- 
tulae, or the establishment of an artificial anus. When peritonitis 
arises from the perforation of the caecum or its appendix, its occurrence 
may be quite sudden and unpreceded by any form of premonitory symp- 
toms; occasionally, however, it is heralded for a longer or shorter time 
by some localized uneasiness or pain ; and occasionally (as we have 
pointed put) it supervenes in the course of well-marked perityphlitis. 

The functions of the alimentary canal are by no means necessarily 
disturbed to any great extent in the course of typhlitis. Sickness is 
often entirely absent. Constipation is not unfrequently present during 
the earlier period of the disease ; while diarrhoea is apt to supervene at 



PERIPROCTITIS. 



627 



a later stage. But none of these symptoms has any particular uni- 
formity or value. It may be remarked that, from the close proximity 
of the caecum to important veins and nerves, typhlitis is apt to induce 
painful neuralgic symptoms and oedema of the right lower extremity. 
The duration of typhlitis is necessarily very uncertain. Sometimes the 
patient speedily recovers, sometimes he lingers for months or years 
with a constantly discharging abscess or a succession of abscesses. If, 
however, perforation take place into the peritoneum death very rapidly 
follows. 

Although inflammation taking its origin in the caecum is a very com- 
mon and important cause of inflammatory swelling and suppuration 
in the right iliac fossa, it must not be forgotten that this part is also a 
very common seat of inflammation and of abscess from other causes, 
and further, that such abscesses are liable to form communications 
with the caecum, and hence still further to simulate primary typhlitis. 
Among the affections here referred to may especially be enumerated in- 
flammation of the ovary and of the connective tissue in its neighbor- 
hood ; idiopathic abscesses of the venter ilii, or in the course of the 
psoas muscle; psoas abscess from caries of the spine; renal abscess; 
and indeed all abscesses descending from above behind the peritoneum 
— abscesses even from the interior of the spinal canal, from the pleura, 
lung, or liver. 

Treatment. — The treatment of typhlitis is in principle, and indeed 
in most of its details, the same as that of enteritis and of other forms 
of ulceration of the bowels. It consists mainly in keeping the bowels 
quiet by the aid of opium, and in the employment of local applications. 
It is almost more important in typhlitis than in any other affection to 
avoid the use of opening medicines; for, especially if the disease be 
in the appendix, rupture into the peritoneum is in many cases pre- 
vented solely by slight adhesions between that body and other organs. 
This danger indeed often continues for some time after the local in- 
flammation seems to have subsided; and caution should, therefore, be 
exercised in respect of the use of purgatives for some time after ap- 
parent restoration to health. If the bowels need to be relieved simple 
enemata are the safest means for the purpose, and are usually sufficient. 
The local measures to be employed comprise leeching, fomentations, 
and the application of ice ; and if an abscess form, its speedy evacuation 
either (according to the circumstances of the case) by the aspirator or 
by incision. Those who have once suffered are very liable to recur- 
rences of the disease, and require to take great care in respect of diet, 
exposure to cold, and other conditions, likely to act injuriously. 

Periproctitis. 

Causation and Morbid Anatomy. — Inflammation and suppuration 
about the lower part of the rectum are even more common than the 
corresponding affections of the caecum ; and their causes are equally 
various. In many cases, no doubt, this affection is traceable to ulcera- 
tion (perforative or other) of the mucous membrane; in others it proba- 
bly originates in the connective tissue which surrounds the rectum. 



628 



DISEASES OF THE DIGESTIVE ORGANS. 



Further, the rectum (again even more frequently than the caecum) be- 
comes involved in inflammation and suppuration originating in the 
various pelvic and even in distant organs. Abscesses, in fact, arising 
in the abdominal cavity or its walls are peculiarly apt to gravitate into 
the pelvis, and to communicate with the rectum. It is an important fact 
that rectal abscess is frequently connected with the presence of tuber- 
culosis. 

Symptoms and Progress. — Inflammation in the neighborhood of the 
lower part of the rectum necessarily produces more or less obvious 
tumefaction and induration which may usually be readily detected by 
digital examination per anum, or by their presence in the perinasum in 
the immediate vicinity of the anus. In connection with the swelling 
there are always more or less severe pain and tenderness, which often 
prevent the patient from sitting down, and are always greatly aggra- 
vated during the act of defecation. If suppuration be going on, the 
swelling rapidly increases in size, and the abscess presently opens either 
into the rectum (usually a little within the internal sphincter), or ex- 
ternally by the side of the anus, or in both of these situations, and dis- 
charges exceeding fetid pus. Simple inflammation around the rectum 
may subside spontaneously ; if, however, suppuration take place, it 
almost invariably results in the formation of a fistula which is always a 
peculiarly obstinate affection, and yields only to direct surgical treat- 
ment. When the abscess opening into the rectum is connected with 
suppuration of remote organs, the ultimate prospects of recovery are by 
no means equally satisfactory. 

The treatment consists in the application of fomentations, poultices, 
or leeches, and the opening of the abscess as soon as the presence of 
pus is ascertained. The bowels, moreover, should be regulated, if nec- 
essary, either by laxatives or the use of enemata. 



DYSENTERY. 

Definition. — We have already, in describing inflammation and ulcera- 
tion of the bowels, discussed the various inflammatory processes which 
take place in the large intestine, and considered the symptoms to which 
they give rise. These affections, especially if they involve its lower 
segment, always induce so-called " dysenteric " symptoms, and are usu- 
ally included in the generic term " dysentery." But dysentery is a 
name which is also applied to one of the most widespread and fatal of 
all diseases — a disease which, under special circumstances or combina- 
tions of circumstances, assumes an endemic or even epidemic character, 
and is hence not unnaturally regarded as a specific disease, in the same 
sense as ague and enteric fever are specific diseases. 

Causation. — Dysentery prevails largely in tropical regions, and more 
especially in those places which are low and swampy, and surcharged 
with decaying vegetable matter, in regions indeed which are, for the 
most part, malarious and breed intermittent fevers. It occurs, how- 



DYSENTERY. 



629 



ever, under conditions and in places which are not productive of ague; 
it lias been in all ages one of the greatest scourges of armies in the 
field, of beleagured cities, and of starving populations. According to 
Sydenham and others of our older writers, it was once a formidable 
disease in this country, whence in an aggravated and epidemic form it 
has now almost entirely disappeared. It is probable, however, that 
enteric fever formed a large proportion of the cases then termed dys- 
enteric. From its frequent coincidence in area of distribution with 
ague it is by many regarded as being, equally with that disease, a 
product of the malarial poison. But the facts that aguish districts are 
not necessarily also dysenteric; that dysentery, even in an epidemic 
form, occurs in places and under circumstances which never yield ague ; 
and that ague and dysentery no more graduate into one another than 
do enteric and typhus fevers, render this view of its origin untenable. 
The influences of foul water, of polluted air, of insufficient nourishment, 
and of exposure and overfatigue in its production are unquestionable, 
but whether as exciting causes or as predisposing causes merely is by 
no means clearly established. There is reason, however, to believe 
that polluted drinking-water is an especially active agent in the induc- 
tion of the disease, but whether by the introduction of a specific poison 
is, at least, doubtful. We are ourselves inclined to regard dysentery 
as both of non-specific origin and non-infectious ; and, on these grounds, 
introduce our description of it here. 

3Iorbid Anatomy. — The morbid anatomy of dysentery has been 
abundantly described, but the descriptions which have been given of 
it are very various, and do not admit of being readily reconciled. 
Some of the most trustworthy of recent observers, such as Parkes and 
Baly, regard it as essentially a disease of the solitary glands of the 
large intestine, which rise up in the form of hemispherical buttons, 
varying from the size of a millet-seed downwards, and occasionally 
attaining the bulk of a split pea. Associated, however, with the 
glandular hypertrophy there are always more or less intense congestion 
of the general surface of the mucous membrane, which becomes sepia- 
colored, reddish-brown, or almost black ; and inflammatory infiltration 
of its substance and of that of the submucous tissue, which may conse- 
quently acquire a collective thickness of one-quarter or even one-third 
of an inch. 

It must, we think, be admitted that dysentery commences with con- 
gestion, more or less intense, and infiltration, more or less conspicuous, 
of the mucous membrane, in which changes the solitary glands not im- 
probably take a predominant share. This inflammation (at all events 
in the first instance) usually occurs in scattered patches, which are 
linear, stellate, or irregularly roundish or polygonal, are peculiarly 
liable to involve the prominent folds, and are sometimes limited to 
them. The patches may be discrete, or they may run together, form- 
ing an irregular network, or they may coalesce completely over a more 
or less extensive area, and even throughout the whole length of the 
large intestine. It usually happens that„ in addition to the interstitial 
inflammatory changes here adverted to, the affected surface becomes 
early covered with a thin, opaque, granular film, or with such films in 



G30 



DISEASES OF THE DIGESTIVE ORGANS. 



patches. These can usually be readily removed from the subjacent 
surface, bringing with them adherent casts of the Lieberkiihnian fol- 
licles. They consist, in fact, mainly of an inflammatory overgrowth of 
the intestinal follicular epithelium. 

If the dysenteric attack be slight, the morbid process may cease at 
this point, and convalescence become established without any material 
injury to the bowel. But if it be severe, further changes speedily 
ensue. These present considerable variety, but consist essentially in 
the formation of sloughs and (by the separation of these) of ulcers. 
The sloughs vary in color, size, shape, and arrangement. They may 
be yellow, like those of enteric fever, or ash-colored, or black. They 
are sometimes circular and distinct, studding the surface more or less 
uniformly and thickly; sometimes they occur in irregular groups, and 
constitute patches of various, and often considerable extent ; sometimes 
they so run together and are so arranged as to constitute a network the 
interstices of which are formed by isolated patches of mucous mem- 
brane ; sometimes extensive tracts of surface are uniformly and com- 
pletely destroyed ; and in all cases there is more or less tendency for 
the morbid process to spread, either by simple ulceration, or by the 
burrowing of pus beneath the mucous surface, or by the extension of 
sloughing. With the separation of the sloughs ulcerated surfaces are 
left, sometimes with ragged, sometimes with abrupt, and often with 
swollen and congested margins, and frith floors formed either by the 
submucous tissue or by the transverse muscular fibres. 

The subsequent progress of the morbid process varies. In some 
cases more or less perfect cicatrization ensues ; in some, the ulcers 
assume a chronic character, and remain open, and with little alteration, 
for months or years ; and in either of these cases there is a tendency 
to the recurrence of active inflammation under slight provocation. 
When the disease lapses into the chronic form, the affected bowel is 
apt to remain exceedingly irritable, to become permanently contracted 
without actual stricture, and as regards its muscular coat sometimes 
greatly hypertrophied. It must be added that perforation of the bowel 
is an occasional complication of dysentery; that inflammation some- 
times pervades the whole thickness of the intestinal walls, extending 
even to the peritoneal surface ; that hemorrhage from the inflamed or 
ulcerated surface to a greater or less degree is almost invariable, while 
in some cases it is so abundant as to cause death ; and that the cicatriza- 
tion of dysenteric ulcers not unfrequently causes stricture. 

Dysenteric inflammation may occupy any part of the large intestine, 
or the whole of it, and may be prolonged for a considerable distance 
up the ileum. It is most common, however, in the lower part of the 
colon and in the rectum, and is usually most severe and most advanced 
in these situations. 

Other lesions besides those affecting the bowels are often met with 
in dysentery. The most common of these are engorgement of the 
lymphatic glands in relation with the inflamed bowel, and congestion 
of internal organs, more especially of the liver, spleen, kidneys, and 
lungs. In association with the dysentery of tropical climates it is not 
uncommon to find abscess of the liver. This complication is referred 



DYSENTERY. 



631 



by Dr. George Budd to portal pyaemia, taking its rise from the diseased 
mucous membrane of the bowel. Hepatic abscess, however, sometimes 
originates simultaneously with the dysentery, sometimes actually pre- 
cedes it ; and hence it seems more probable that the two lesions are 
concurrent effects of the same cause, and not dependent the one on the 
other. 

Symptoms and Progress. — The symptoms of dysentery comprise 
those of pyrexia and those directly due to the morbid processes going 
on in the large intestine — these latter being mainly determined by the 
excessive irritability and tendency to spasmodic contraction of the larger 
bowel, and by the fact of the constant discharge into it of the morbid 
products of the diseased mucous surface. 

In the milder forms of the disease, the patient, after suffering, per- 
haps, for a short time from more or less heat and dryness of skin, clam- 
miness of mouth, and vague griping pains, is attacked almost suddenly 
with an uncontrollable impulse to evacuate his bowels, and probably 
passes a solid motion with unusual ease, the mass being invested in a 
greater or less abundance of grayish or colorless mucus. The usual 
sense of relief, however, does not follow, and he probably finds him- 
self compelled to sit straining at stool, with fits of spasmodic violence, 
during which he discharges small quantities of offensive mucus, and 
probably a minute fecal lump or two. With the continuance of the 
affection the febrile disturbance continues ; the tongue probably be- 
comes coated ; a constant sense of uneasiness, or heat, or burning per- 
vades the anus and adjoining parts of the rectum, and more or less, 
perhaps, of the rest of the large intestine. The patient suffers from 
frequent tormina, and frequent more or less uncontrollable impulse to 
evacuate the bowels — the efforts being attended with great tenesmus, 
and the discharge mainly of small quantities of mucus. This may be 
stained with fecal matter, and is often intimately mixed with blood, 
and may consequently present very much the appearance of pneumonic 
expectoration. But, notwithstanding the almost constant efforts at 
defecation, there is, so far as actual fecal matter is concerned, almost 
complete constipation. A few scybala only are passed from time to 
time. Cases of this kind may subside in the course of a day or two, 
and rarely last longer than a week or ten clays. Nevertheless some 
irritability of the bowels, some uneasiness after defecation, and some 
tendency to constipation may trouble the patient for a considerable 
time after he seems to have regained in other respects his ordinary good 
health. 

In the more severe forms of dysentery the symptoms are similar in 
kind, but much more intense. The disease is usually ushered in with 
high fever, often with alternate chills and flushes of heat, sometimes 
with distinct rigors, and occasionally even with convulsions. The skin 
is hot, the pulse accelerated, there are febrile pains and headache, and 
more or less anorexia, thirst, and dryness and furring of the tongue. 
In this, as in the former case, the affection of the bowels is usually first 
indicated by the occurrence of griping pains, which are presently fol- 
lowed by the evacuation of the contents, often solid, of the lower bowel. 
But very soon the griping becomes frequent and severe, calls to stool 



632 



DISEASES OF THE DIGESTIVE ORGANS. 



are incessant, and the patient suffers from almost constant tenesmus. 
The matters discharged from the bowels are at first a whitish, brownish, 
or olive-colored glairy or jelly-like mucus ; but this soon becomes 
sanguinolent, and not unfrequently intermingled with considerable 
quantities of dark and more or less clotted blood. After a while the 
discharges commonly assume those characters which give. them a re- 
semblance to " meat- washings ;" they become thin, watery, turbid, 
reddish and dirty-looking, and contain brownish or blackish particles, 
which are either fragments of altered blood-clots or of sloughy mucous 
membrane. It is at this time also that the patient frequently passes 
soft membranous pellicles, which are either tracts of mucous membrane 
detached in bulk, or portions of false membrane. Dysenteric evacua- 
tions are further characterized by a peculiar and almost insupportable 
fetor, which increases in intensity with the supervention of sloughing; 
by containing a large quantity of dissolved albumen ; and by the oc- 
casional presence of small solid fecal lumps or scybala. They some- 
times become purulent. The frequency with which the bowels act is 
often very remarkable. In some cases the patient seems for a, length 
of time never to cease discharging small quantities of fluid. The bowels 
are often relieved four or five times in the hour, and sometimes as many 
as ten or twenty times in the same period. The quantity of fluid 
passed is not, however, necessarily in relation with the frequency with 
which the bowels act. In many cases, especially at the beginning, the 
discharge is very scanty ; later on, however, large quantities of serous 
fluid, or of blood, or both, are apt to escape, and the total bulk of 
these discharges in the twenty-four hours is hence often very large. 

Associated with the tenesmus and alvine flux are burning pain 
within the anal orifice, and a constant sense of the lodgment there of 
something which needs to be got rid of ; there are also more or less 
burning pain and tenderness on pressure in the course of the large 
intestine and especially of those parts of it which are chiefly involved. 
At first probabty the abdominal parietes are rigid and retracted; but 
before long the bowels get distended with flatus and the abdomen con- 
sequently enlarged and tympanitic ; the tongue becomes thickly coated; 
the patient complains much of thirst, loathes food, and not unfre- 
quently suffers also from nausea and vomiting ; the urine is scanty and 
high-colored, and its discharge sometimes attended with pain or diffi- 
culty ; the febrile excitement which ushered in the disease very rapidly 
becomes replaced by a condition of profound depression ; the skin may 
yet be hot and dry, but the pulse becomes small, feeble, and very 
rapid, the face anxious, and the patient restless, sleepless, and de- 
sponding. 

Cases which end favorably usually manifest signs of amendment 
from the sixth to the tenth day ; these consist in abatement of fever 
and other general symptoms, and the gradual cessation of tenesmus 
and of the peculiar dysenteric stools. Convalescence is usually, how- 
ever, much protracted, and some time elapses before the bowels com- 
pletely regain their normal tone. In those cases which end fatally the 
pulse increases in rapidity, loses fulness and power, and often becomes 
scarcely perceptible ; the surface tends to grow cool ; the face and 



DYSENTERY. 



633 



extremities acquire a shrunken and dusky aspect ; the tongue becomes 
dry and brown or black ; hiccough and vomiting come on ; and the 
abdomen gets more and more tympanitic. Although probably con- 
tinuing restless and desponding, the patient often retains his senses 
perfect to the last ; sometimes, however, he becomes delirious (in some 
cases, indeed, delirium comes on early), and he may then pass into a 
state of stupor or coma. It very commonly happens that, with the 
increase of tympanites, the abdominal pain, colic, and tenesmus all 
subside and perhaps wholly disappear. The symptoms which precede 
death, and the mode of death, will necessarily be to some extent modi- 
lied by the special circumstances of the case; they will, for example, be 
somewhat different in those cases which are attended with profuse 
haemorrhage from what they are in those in which intestinal perfora- 
tion takes place, or in those in which there is an hepatic abscess, or in 
those again where the patient sinks under the influence of the uncom- 
plicated disease. Under all circumstances, however, the immediate 
cause of death is asthenia. 

A considerable number of cases of acute dysentery, instead of taking 
either of the two courses which have been considered, become chronic; 
and the disease continues, with occasional remissions and exacerbations, 
for an indefinite period. The patient is then an almost constant 
sufferer from colic and tenesmus and the discharge of offensive liquid 
stools, containing little true fecal matter, and from retention, often to 
a very uncomfortable extent, of his solid faeces ; he complains of ab- 
dominal tenderness and uneasiness ; his tongue is in some cases dry, 
glazed, and fissured, in others coated, in others almost normal; and 
his appetite presents equal variations; more or less sickness is often 
present; and he becomes emaciated, weak, anaemic, anasarcous, and 
often hectic. If an hepatic abscess be present, the symptoms, or many 
of them, are aggravated, and presently probably the indications of 
hepatic tumor are superadded. It need scarcely be stated that chronic 
dysentery varies greatly in its severity, and that some cases, although 
lasting for years or throughout life, are, excepting from the discomfort 
which attends them, of comparatively little importance. 

As a rule, sporadic dysentery is not a very fatal disorder ; the epi- 
demic form, however, is usually attended with a high mortality ; and 
although, even in this case, the ratio of deaths to attacks is sometimes 
small, the cases are so numerous and the total mortality usually so 
high, that it is justly regarded as one of the most fatal of epidemic 
diseases. 

Treatment. — There is little unanimity of opinion with regard to the 
treatment of dysentery; some authors strongly advocate the copious 
abstraction of blood, if not by venesection, at any rate by leeches ; some 
place their chief reliance on calomel in large doses ; some regard ipe- 
cacuanha as almost a specific ; some pin their faith to purgatives, some 
to opiates ; while, on the other hand, each of these remedies has been 
more or less strongly condemned. Of the immediate relief which 
follows the abstraction of blood there is probably little doubt ; but it is 
obvious that the marked tendency to asthenia which exists in dysentery 
supplies a powerful argument against the indiscriminate and excessive 



634 



DISEASES OF THE DIGESTIVE ORGANS. 



use of bloodletting. As a rule, it is doubtless unnecessary, and if 
employed should be employed early, and preferably should be effected 
by the application of leeches to the tender regions of the abdomen. 
Calomel has been administered (as it was formerly in cholera) in large 
doses and with reputed success ; it has, however, fallen into disuse, 
and probably deservedly. Ipecacuanha has enjoyed a long but various 
reputation. It was formerly regarded as an almost unfailing specific, 
and at the present day is very highly esteemed. There are at least 
two antagonistic principles on which it is administered. By Trousseau 
and other French authorities it is given in doses of ten or twelve grains 
of the powder every ten minutes or so, until copious vomiting results, 
the essence of the treatment being, according to them, the production 
of a powerful evacuating effect upon the stomach; by English army 
surgeons, on the other hand, it is recommended to be given in a large 
dose (twenty-five to thirty grains), which is to be repeated at the end 
of eight or ten hours ; but it is to be given guarded by opium, and with 
every precaution against sickness, in order that the remedy may act 
directly, or indirectly through the system, on the affected mucous sur- 
face. Bretonneau advocated the use of saline purgatives in large doses, 
and in this advocacy he is strongly supported by Trousseau. Opium 
and astringents are often employed, but the former especially (except 
in infinitesimal doses) is strongly condemned by the last author. 

It may however, we think, be fairly asked whether there are any 
good grounds for believing that dysentery is more amenable to treat- 
ment, specific or non-specific, than other forms of enteritis are ; and 
whether there are any good grounds for adopting any radically differ- 
ent treatment from that which has been found generally useful in 
enteritis? In acute and severe cases we should be disposed in the first 
instance to apply hot fomentations to the belly, and if there be much 
local pain and distress, to abstract blood by means of ten, twenty, or 
thirty leeches; to exhibit opium, or opium with ipecacuanha, in doses 
sufficiently large or sufficiently frequently repeated to relieve the tor- 
mina, tenesmus, and abdominal pain ; and to use enemata either simply 
to wash out and cleanse the lower bowel, or to soothe it, or for the 
purpose of applying astringent or other medicaments directly to its 
surface. We should prefer, in the early stage of the disease, small 
enemata of gruel containing laudanum, or opium or morphia supposi- 
tories. The patient's diet should consist of milk, gruel, broths, eggs, 
and such like articles, together with such a proportion of alcoholic 
stimulants as the case may seem to need. If sickness be present, it 
must be treated with ice and such remedies as are generally useful in 
relieving sickness. When the dysentery passes into the chronic state, 
the use of astringent medicines and of vegetable tonics is indicated. 
The former may comprise copper, lead, iron, tannin and other vegeta- 
ble astringents, the latter a wide range of vegetable infusions. At 
this period also enemata are likely to be particularly serviceable ; and 
especially enemata containing copper, lead, tannin, sulphate of zinc, or 
nitrate of silver, have been strongly recommended, in the belief that 
they act directly beneficially on the diseased mucous membrane. We 
believe it to be a good plan to wash out the bowel night and morning 



PERITONITIS. 



635 



with as large an injection of warm water or gruel as can be introduced 
without pain, and then to insert a morphia suppository. In treating 
dysentery it must not be forgotten that both in acute and in chronic 
cases fecal matter tends to accumulate above the diseased portion of 
bowel, and that this needs to be from time to time removed. For this 
purpose it may be necessary to administer an occasional purgative. In 
mild cases of dysentery it is often well to commence the treatment with 
a dose of castor-oil, and to continue it with mild astringents, such as 
the compound kino powder or Dover's powder, or the aromatic chalk 
and opium. 



PERITONITIS. 

Causation. — Peritoneal inflammation is an affection of by no means 
unfrequent occurrence in both sexes and at all periods of life. It 
results from the operation of various causes. In some cases it is idio- 
pathic, or due to exposure to cold and wet, or generally to those exte- 
rior conditions to which inflammations of other organs are so commonly 
traceable. Idiopathic peritonitis (the occurrence of which has been 
erroneously denied) may attack the robust and healthy; it is doubtless, 
however, more common in those who are anaemic or debilitated, or 
broken down in constitution, and in those who suffer from obstructive 
diseases of the heart, lungs, or liver, and especially in such as are la- 
boring under chronic Bright's disease of the kidneys. In many cases 
peritonitis is due to the simple extension of inflammation from neigh- 
boring parts. It is thus developed in the course of enteritis or gas- 
tritis, in connection with inflammatory affections of the liver, spleen, 
kidneys, or bladder, and in dependence on pleuritis, pericarditis, or 
suppurative or other inflammation taking place in any part of the ab- 
dominal parietes. The most fruitful causes, however, of inflammation 
(or rather perhaps of grave inflammation) by simple extension, are in- 
flammation of the ovaries, uterus, and other pelvic organs in females, 
and especially that form of uterine inflammation which follows upon 
parturition. In many cases, again, peritonitis is caused by mechanical 
injury — sometimes by external wounds; more frequently by the per- 
foration or rupture of some viscus and the extravasation of its contents 
or of foreign matters into the peritoneal cavity. Among such causes 
must be enumerated ulcerative perforation of the stomach and duode- 
num ; perforation of the small intestine (usually the ileum) as a conse- 
quence of tubercular, or typhoid, or other form of ulceration ; perfora- 
tion of the caecum, vermiform appendix, colon, or rectum, consecutive 
to tubercular or typhoid ulcers, to dysenteric disease, or to mere over- 
distension ; rupture of an hepatic abscess, or of the gall-bladder or 
common bile-duct, or of an hydatid cyst, or of a psoas, renal, or other 
abscess ; rupture of the bladder or uterus, or of ovarian cysts ; and, 
besides these, the laceration, from external violence, of the liver, 
spleen, kidneys, intestine, or bladder. Further, peritonitis is a fre- 



636 



DISEASES OF THE DIGESTIVE ORGANS. 



quent concomitant of abdominal tubercle or carcinoma, and is not very 
uncommonly the result of pyemic or metastasic processes. 

Morbid Anatomy. — The morbid changes which take place in the in- 
flamed peritoneum are precisely similar to those which attend inflam- 
mation of other serous membranes. They consist in dilatation of the 
minute vessels, with accumulation of blood within them, and infiltra- 
tion and thickening of the subserous tissue; and in inflammatory 
hyperplasia of the epithelial investment, with the effusion from the 
subjacent vessels of the modified plasma of the blood, of which part 
coagulates on the surface, forming, with entangled corpuscles, a false 
membrane, and part (mainly fluid) accumulates in the cavity. The 
first visible indications of peritoneal inflammation consist in most cases 
in more or less intense capillary congestion, which is usually observed 
to extend in bands (determined by the pressure of the organs against 
one another) along the intestines ; and in more or less loss of polish, 
due to the commencement of inflammatory exudation. With the ad- 
vance of the disease, the congestion often becomes more intense, gener- 
ally patchy, and sometimes complicated with subserous extravasa- 
tion of blood; and the inflammatory exudation increases in quantity. 
This last forms in the first instance a thin, grayish, granular lamina; 
but, gradually increasing in thickness, soon acquires a more distinctly 
yellowish tinge, and becomes, according to its quantity and position, 
ribbed, or villous, or papular, or honeycombed. The false membrane 
may vary in thickness from a mere film to a thickness of a quarter or 
half an inch, or more; and in consistence from a mere pulp to that of 
a coherent elastic lamina. It usually becomes more coherent with its 
age; and the deeper-seated portions are always tougher than those 
which are more superficial. It tends to gravitate into the dependent 
portions of the peritoneal cavity, and to accumulate there, and further 
to cause more or less intimate adhesion between neighboring organs. 
The fluid effused in the course of peritonitis is very often small in 
quantity, and, subsiding into the pelvis and lumbar regions, may thus 
escape observation ; on the other hand, it is sometimes very copious, 
and causes much abdominal distension. It becomes chiefly abundant 
in chronic cases. It is usually opalescent, containing exudation cor- 
puscles and fibrinogen, which may be readily made to coagulate. The 
spaces occupied by the fluid are commonly traversed by filaments, or 
bands, or bridles, of coagulated lymph. 

' Peritonitis, even when of local origin, generally soon involves the 
whole of the peritoneal surface. In some cases, however, it remains 
localized. Thus it is sometimes limited to the neighborhood of the 
liver or spleen, sometimes to that of the csecum, sometimes to that of 
the pelvic organs. The great omentum not very unfrequently effectu- 
ally limits its spread. Convalescence from simple peritonitis is attended 
with absorption of the dropsical effusion, subsidence of the inflamma- 
tory congestion, organization of the false membrane, and its gradual 
conversion into contracting connective tissue. And the consequences 
usually are that the peritoneal surface becomes thickened and opaque, 
and the viscera united to neighboring parts and compressed by more 
or less tough adhesions. The liver and spleen thus adhere to the 



PERITONITIS. 



637 



diaphragm ; the small intestines stick to one another, and are not un- 
frequently welded into an apparently homogeneous lump. Further, 
the liver and spleen, and other organs in a less degree, are apt to be- 
come studded more or less closely with opaque fibroid patches, which 
may attain a thickness of J inch or more, and present an almost car- 
tilaginous consistence and aspect. 

In many cases peritonitis becomes suppurative. Sometimes, as in 
the puerperal variety, the inflammation presents this character univer- 
sally and from the beginning; the effused lymph is more abundant, 
more opaque, more yellow, and more pulpy than in non-suppurative 
cases, and obvious pus is poured out into the peritoneal cavity. In a 
large number of cases, and especially in such as result from the per- 
foration of some viscus or sac and the escape of irritating matters, 
general peritonitis of the ordinary adhesive character is at once excited, 
and the effused matters consequently become confined to some limited 
district or districts. In many cases a circumscribed abscess is thus 
produced which may possibly undergo cure by the discharge of its con- 
tents either externally or into the bowel. But in some cases groups of 
such abscesses form and sinuses extend in various directions, either 
among the peritoneal adhesions, or in the substance of the mesentery, 
mesocolon, great omentum, and other such parts; and fistulous open- 
ings may be established in various situations. General suppurative 
peritonitis may of course result from the escape of fecal or other irri- 
tant matters into the peritoneum, especially if the escape be sudden 
and profuse. And in this case if the accident be not immediately 
fatal the false membrane becomes exceedingly thick and tough, and 
the general surface acquires the usual characters of that of a chronic 
abscess. 

Occasionally in peritonitis as in other serous inflammations copious 
haemorrhage takes place from the newly-formed vessels of the adhesions 
into the serous cavity. 

Symptoms and Progress. — The symptoms of peritonitis are mainly 
those of fever in combination with acute abdominal pain, increased by 
pressure. These symptoms are liable, however, to considerable 
variety ; and many others of more or less importance are usually 
superadded. The phenomena of peritonitis differ, indeed, greatly in 
relation with the extent and intensity of the inflammation and the cir- 
cumstances under which it arises. 

Acute idiopathic peritonitis, although by far the least frequent 
variety, yet displays the symptoms and course of the disease in their 
simplest and most typical form. Its mode of onset varies. Some- 
times the outbreak of the local affection is preceded by a few days of 
vague sense of illness ; sometimes it is marked by the occurrence of 
febrile symptoms, and even of rigors ; sometimes the first indications 
of disease are sudden vomiting or purging, or both, or gradually 
increasing dysuria, or in females the occurrence of menorrhagia. But 
whatever the initiatory symptoms, the patient before long complains of 
more or less marked febrile disturbance, and of burning, aching, 
pinching, or cutting pains, probably limited to some region of the ab- 
domen, and increased by pressure or by movement. The pain is 



638 



DISEASES OF THE DIGESTIVE ORGANS. 



usually in the first instance across the lower part of the abdomen ; and 
if the patient have not yet taken to his bed, he sits and walks and 
moves with his body bent into a stooping posture. Soon, however, the 
signs of peritoneal inflammation extend and increase in severity; and 
at the same time the patient's general symptoms assume a more serious 
aspect. The abdominal pain becomes exceedingly severe, and is 
aggravated beyond endurance by the slightest movement. He takes 
to his bed, where he lies motionless on his back, with his head and 
shoulders elevated, and his thighs and legs flexed so as to diminish as 
far as possible the pressure of the abdominal walls on the internal 
organs ; and breathing by means of the intercostal muscles only, and 
shallowly, with the same object. He not only cannot bear the pressure 
of the hand, but generally cannot even endure the weight of the bed- 
clothes, or of the poultices or fomentations which may have been 
ordered for his relief. The pain is not unfrequently comparatively 
trivial so long as perfect rest is maintained; but it breaks out afresh 
whenever a cough or a sneeze, or a hiccough, or a deep inspiration 
takes place, and is liable to periodical and in many cases frequent ag- 
gravations, due to the peristaltic movements of the bowels. In associa- 
tion with these phenomena there is generally distinct fever. The 
temperature may reach 101° or 105°, but is very often not above 100° 
or 101°. The skin is hot and dry; the face flushed; the pulse in- 
creased in frequency and sharpness ; the respirations augmented to 30 
or 40 in the minute; and the tongue more or less coated and clammy, 
if not dry. Vomiting is often present, but is no necessary feature of 
the disease; and thirst is usually complained of. The bowels are gen- 
erally constipated, but are not unfrequently loose. The urine is scanty, 
high-colored, and sometimes retained in the bladder ; or there may be 
irritability of the bladder with painful micturition. It may be ob- 
served that the presence of marked intercostal respiration indicates in- 
volvement of the upper part of the abdominal cavity ; interference 
with micturition involvement of the pelvic portion of the peritoneum ; 
and, further, there is reason to believe that the occurrence of vomiting 
and of diarrhoea are referable in some cases to the implication of the 
serous surface of the stomach and bowels respectively. If the disease 
take a favorable turn, which indeed at the end of a few days it usually 
does, the severer symptoms gradually remit ; abdominal pain and ten- 
derness subside, vomiting ceases, the respirations become natural, and 
the temperature and pulse return to their normal condition. If, on 
the other hand, the case be about to prove fatal, important changes in 
the symptoms more or less quickly supervene; the abdomen becomes 
distended, partly it may be from effusion of fluid, mainly, however, 
from accumulation of gas in the intestines ; and the pain and tender- 
ness, though sometimes continuing and even becoming aggravated, 
very frequently undergo great diminution and sometimes entirely 
cease ; sickness very probably increases, and hiccough supervenes ; the 
temperature falls, the extremities become cool or cold, the face pale or 
livid, and pinched and anxious in expression, and the skin suffused 
with cold perspirations ; the pulse increases in frequency, rising it may 
be to 130, 140, or 160 in the minute, and gets small, thready, and 



PERITONITIS. 



639 



weak ; the respirations become more rapid, reaching, perhaps, 40 or 
even 60 in the minute ; and the tongue becomes more thickly coated, 
and this and the lips dry. The patient, in fact, retaining for the most 
part his consciousness, rapidly falls into a state of profound collapse, 
in which he presently dies. Sometimes more or less delirium comes on 
before the fatal event, and death may then be preceded by coma. 

The tendency to failure of the circulation and to collapse is one of 
the most remarkable characteristics of peritonitis, as it is of enteritis ; 
and it is important to bear this fact in mind, for even in the early stage 
of the disease, when the pulse is little accelerated, and sharp, perhaps 
strong, and the patient appears to be suffering from what is termed 
" the sthenic form " of peritonitis, a little over-exertion, some unwonted 
effort, may readily induce dangerous collapse. 

It may be added that the presence of dropsical effusion adds to the 
distension of the abdomen, but does not, as a rule, materially aggra- 
vate the danger of the case ; and that, if sufficiently abundant, it may 
be detected either by its causing dulness and bulging in the flanks, or 
by the presence of fluctuation; further, that peritoneal inflammation 
constantly causes pleuritis at the base of the pleurae, which may possibly 
be recognized during life, and that peritoneal friction may also occa- 
sionally be detected either by the fremitus it occasions or by ausculta- 
tion. Death may occur as early as the second or third day of the attack, 
or may be delayed to the end of a week or even ten days. When cases 
are prolonged, however, beyond this date they usually lapse into the 
chronic condition ; in which either inflammation of little intensity is 
kept up by the formation of tubercles or by some other cause, or in 
which the chronic symptoms are due to the formation of a circumscribed 
abscess. 

Puerperal peritonitis differs from the affection which has just been 
considered chiefly in the circumstances under which it arises, in its 
usually rapidly fatal course, and in the fact that it is very often indeed 
associated with, if not dependent upon, pyaemia taking its origin in 
inflammation of the uterine mucous membrane. It usually commences 
within a few hours or a few days after parturition, with severe rigors, 
attended with high elevation of temperature, and soon followed by 
intense pain across the lower part of the belly, and suppression or 
modification of the lochia! discharge. The main points in its symp- 
tomatology, by which it differs from the idiopathic affection, are the 
speedy supervention of collapse, and the more general and early impli- 
cation of the sensorial functions. Further, the symptoms, are, in many 
cases, compounded of those of the local affection and those of pyaemia. 

Peritonitis from perforation is one of the most frequent and interest- 
ing forms of the disease, and by far the most fatal of them. When 
perforation takes place in a person who appears to have been, up to 
the very moment of the accident, in the enjoyment of good health, as 
we sometimes see in cases of perforating ulcer of the stomach, or of 
rupture of the urinary bladder, or of perforation of the ileum in mild 
cases of enteric fever, the symptoms usually are : intense and sudden 
pain in the region of the perforated organ, speedily followed by all the 
local indications of violent peritoneal inflammation ; and extreme and 



640 



DISEASES OF THE DIGESTIVE ORGANS. 



immediate collapse, indicated by pallor and coldness of surface, cold 
sweats, feeble, scarcely perceptible pulse, fainting, and vomiting. In 
some cases the patient dies of this primary collapse in the course of a 
few hours ; and there may be little in the history or symptoms of the 
case to distinguish it from one of Asiatic cholera, fatal before the super- 
vention of diarrhoea; or from a case of sudden effusion of blood into 
the stomach and bowels, fatal without hsematemesis or melaana; or 
from a case of ruptured heart or internal aneurism. But frequently 
the patient rallies somewhat, and the collective symptoms of inflamma- 
tion, fever, and peritoneal mischief become more clearly developed. 
Collapse, however, generally soon reappears, and the patient then 
usually sinks after a period varying between tw T elve hours and two or 
three days. The symptoms of perforative peritonitis are not always, 
however, so intense and striking. They are indeed very often exceed- 
ingly difficult of recognition and vague, when they occur in the course 
of abdominal diseases, themselves attended with symptoms which tend 
to mask them — in enteric fever to wit, in dysentery, in enteritis, and 
in those rare cases in which peritoneal suppuration causes perforation 
of the bowel from its serous aspect. By far the most common of these 
cases of masked perforative peritonitis are those which occur in the 
second or third week of severe enteric fever, when the patient is pros- 
trate with diarrhoea, and is dull, confused, and delirious, and to a con- 
siderable extent insensible to painful and other impressions. The 
evidences of perforation in such cases are to be sought, not so much in 
obvious sudden collapse or intensity of abdominal pain, as in the gen- 
eral indications of failing strength, namely, increased weakness and 
rapidity of pulse, coldness of extremities, and lividity of face, diminu- 
tion of intelligence and of power over the limbs and sphincters, and in 
the supervention or increase of tympanites, with general abdominal 
tenderness, as shown by the expression and actions of the patient when 
pressure is made upon the surface of the abdomen. But although 
peritonitis from perforation is a well-nigh hopeless affection, there is 
reason to believe that it is not entirely hopeless. We have known of 
a case in which the patient certainly survived the accident for a fort- 
night, and several cases have been put on record in which there are 
good grounds for believing that a cure was effected after the formation 
of an abscess and its discharge by the bowel or some other route. 

Peritonitis is not always the serious disease wmich has been above 
described. In a large number of cases it is, even if general, slight; 
and in a large number of cases, also, it is of local origin, and continues 
localized. The symptoms of localized peritonitis are the same in kind 
as those of the more general and more severe affection ; but the local 
indications of disease are limited to some comparatively small area, and 
the general symptoms, if there be no serious complications, are com- 
paratively slight. 

It must not be forgotten that the adhesions which peritonitis leaves 
behind are not unfrequently a source of discomfort or danger. In some 
cases the compression of the bowels which they induce keeps up a ten- 
dency to colicky pains and to bowel disturbance; in some cases slowly 
contracting adhesions gradually compress a length of bowel and render 



PERITONITIS. 



6 41 



it practically impervious; while in other cases, again, bridles or bands 
are formed, behind which coils of bowel are apt to slip and to become 
incarcerated or strangulated. 

It may, in conclusion, be mentioned that peritonitis is most liable to 
be confounded with enteritis and colic; but that it is generally dis- 
tinguished from enteritis by the absence of intestinal obstruction, and 
from simple colic by the fact that the latter is unattended with fever, 
and that its pain is usually relieved in some degree by pressure. 

Treatment. — The principles of treatment in peritonitis are sufficiently 
simple; they are, the maintenance of perfect rest, the administration of 
opium, and the application of leeches and other remedial agents to the 
surface of the abdomen. The patient should be placed and propped up 
in that position which he finds easiest, usually upon his back, with his 
knees and shoulders elevated. His abdomen should be defended from 
the weight of bedclothes by means of a suitable cradle ; opium, or mor- 
phia should be given sufficiently frequently, and in sufficiently large 
doses to assuage the patient's pain and keep it in abeyance, to quiet the 
action of the bowels, and to promote comfort and sleep ; it may be 
given by the mouth or by subcutaneous injection. If the case be severe 
and in an early stage, from ten to thirty or forty leeches should be 
applied to the surface of the abdomen ; and bleeding should be pro- 
moted by fomentations or light poultices. Subsequently hot fomenta- 
tions, turpentine epithems, mustard plasters, or blisters, may prove 
serviceable. On the other hand, cold applications — evaporating lotions, 
cold compresses, and ice-bags — have been largely advocated, and in 
many cases have proved of great advantage. It is important, more- 
over, in many cases, to relieve accidental complications, such as nausea 
and vomiting, dysuria, and the like. To meet the former indications, 
recourse must be had to ordinary antiemetic measures; to meet the 
second, the catheter may need to be employed. It is of course essen- 
tial to maintain, as far as we possibly can, the patient's bodily strength ; 
for which purpose nourishing diet, mainly in the fluid form, must be 
frequently administered in small quantities, and alcoholic stimulants, 
in amounts depending on the condition of the patient, combined there- 
with. If he cannot retain food on the stomach, it must be administered 
by the rectum. It need scarcely be said that cases of peritonitis passing 
rapidly into collapse, and especially therefore cases of puerperal peri- 
tonitis, bear depletory measures less w T ell than others; and that hence 
such measures are admissible only quite in their early stage. These 
cases, moreover, demand, more than others, early and considerable 
stimulation; and ammonia and ether, or similar agents, may be em- 
ployed in addition to alcohol. When peritonitis is caused by perfora- 
tion, our main reliance must be placed upon opium; and here especially 
it is of vast importance that the movements of the bowels should be 
restrained, that purgatives should be religiously avoided, and that the 
stomach should not be overloaded with nutriment. If the patient sur- 
vive for two or three days, some hope (remote, no doubt) may be enter- 
tained of his final recovery. But in order to promote this consumma- 
tion, it is always desirable to investigate carefully from day to day the 

41 



642 



DISEASES OF THE DIGESTIVE ORGANS. 



condition of the abdomen in order to detect the presence of any circum- 
scribed abscess there, and as soon as may be to evacuate its contents. 



CIRRHOSIS OF STOMACH AND BOWELS. 

Fibroid infiltration, or thickening, a condition also termed cirrhosis, 
and having a close anatomical relation with cirrhosis of the liver, occa- 
sionally takes place in the walls of the stomach and intestine. Thick- 
ening, which differs little, if at all, from this, is usually present in the 
neighborhood of chronic ulcers of the stomach. When occurring inde- 
pendently, all the coats of the stomach are usually implicated, but more 
especially the muscular coat and the submucous tissue, the mucous sur- 
face being thrown into prominent folds over the affected area. The 
whole stomach is sometimes thus diseased, and is then usually dimin- 
ished in size, tough, and retaining its form like an india-rubber bottle. 
More commonly, however, the affection is limited to the neighborhood 
of the pylorus, which then becomes constricted, a condition leading to 
general dilatation of the stomach. The gastric walls, especially at the 
pyloric end, sometimes attain a thickness of half an inch or an inch, 
and present to the naked eye most of the usual characters of scirrhus. 
The morbid growth differs, however, from scirrhus in consisting wholly 
of fibroid tissue, and in not possessing malignant properties. The in- 
testines are occasionally similarly affected, but much less frequently 
than the stomach. 

The symptoms referable to this condition are exceedingly vague. 
They resemble indeed, for the most part, those of the early stages of 
carcinoma. When the pylorus is obstructed, the symptoms of that 
condition necessarily manifest themselves ; when the large intestine is 
involved, the phenomena of stricture presently supervene. 



TUBERCLE. (Abdominal Phthisis.) 

Morbid Anatomy. — 1. Bowels. — Tubercular disease of the mucous 
membrane of the stomach is so rare, and so little is known about it 
clinically or otherwise, that it is needless to do more than record the 
fact of its occasional occurrence. The mucous membrane of the bowels, 
on the other hand, is one of its most frequent seats, and, indeed, intes- 
tinal ulceration is, in a very large proportion of cases, of tubercular 
origin. Tubercle of the bowels occurs in rather more than one-half of 
the total number of cases of pulmonary phthisis, and rarely, if ever, 
independently of it; it is frequently associated, also, with tuberculosis 
of the peritoneum and other abdominal organs. It primarily affects 
Peyer's patches and the solitary glands ; and in the small intestine is, 
therefore, always most abundant and most advanced immediately above 



ABDOMINAL PHTHISIS. 



643 



the ileo-csecal valve, from whence upwards, even though it extend 
throughout the whole ileum and jejunum, it gradually diminishes. It 
affects the caecum more frequently than any other part of the large in- 
testine, involving also the ileo-csecal valve and vermiform appendage; 
but it may form patches throughout the whole length of the colon. 
The large and the small intestines are affected with equal frequency, 
and are affected conjointly about twice as often as each is affected sep- 
arately. The tubercles appear as gray granules, or yellow cheesy 
masses, in the substance of the glands, and generally soon undergo 
softening, producing small, cleepish ulcers, with thickened, overhang- 
ing edges. When several tubercles have softened side by side, as occurs 
in Peyer's patches, the ulcerated area presents in the first instance a 
kind of honeycombed appearance, the small ulcers being separated 
from one another by bridles of yet undestroyed and thickened mucous 
membrane ; and the general margin, which is also thickened, presents 
a sinuous or scalloped outline. Tubercular ulcers generally tend to 
spread by the successive formation and softening of tubercles at their 
edges, the tubercles not being then necessarily limited to the glands ; 
and thus they often creep over a considerable area. The whole mucous 
lining of the caecum is sometimes destroyed in this manner, and exten- 
sive tracts of ulceration often stud the surface of the colon, at more or 
less distant intervals. In the small intestine tubercular ulcers have a 
remarkable tendency to spread transversely, and frequently form bands 
from half an inch to an inch or more wide, occupying the whole cir- 
cumference of the bowel. In most cases the ulcerative process pro- 
gresses up to the patient's death, and occasionally leads to serious haem- 
orrhage or to perforation. Sometimes the ulcers cicatrize more or less 
perfectly ; some, indeed, cicatrizing while others are spreading or new 
ones forming. Tubercular cicatrization is very apt to lead to consid- 
erable contraction of the bowel and even to the production of stricture. 
Sometimes, again, tubercles dry up or become absorbed without under- 
going ulceration, leaving behind them pigmented cicatrix-like patches 
which have some resemblance to the scars produced in the skin by su- 
perficial lupus. It may be added that extensive ulceration of the large 
intestine, which has all the characters of chronic dysenteric ulceration, 
is often met with in cases of chronic phthisis, in which there is no dis- 
coverable tubercle in any part of the bowels except the ileum, and where, 
therefore, it may be a question as to whether the ulceration is of tuber- 
cular origin, or has arisen in mere non-specific excoriation such as might 
be caused by the constant passage of irritating secretions from the tu- 
bercular bowel above. 

2. The peritoneum and the abdominal lymphatic glands are by no 
means imfrequently affected. Generally, in cases of tubercular ulcera- 
tion of the bowel, and certainly in all cases of extensive ulceration, 
gray granulations stud in greater or less abundance the serous surfaces 
corresponding to the areas of mucous ulceration. But such formations 
are for the most part purely local, and of little importance. There are 
other cases, however, far less common, yet still not unfrequent, in which 
the tendency to the growth of tubercles is general throughout the serous 
membrane, and in which ulceration of the bowel is evidently not their 



644 



DISEASES OF THE DIGESTIVE ORGANS. 



starting-point, and, indeed, is often altogether absent. Peritoneal tuber- 
culosis is almost always associated with similar disease of other parts; 
most commonly with pulmonary phthisis, but not unfrequently with 
tubercular affection of the bowels and other abdominal organs. It 
complicates a very large proportion of those cases in which the pleurae, 
the spleen, the liver, the kidneys, the uterus and Fallopian tubes, or 
the brain are involved. Peritoneal tubercles are sometimes miliary 
and gray, and from the size of a poppy seed downwards. Sometimes 
they form tabulated masses from the size of a tare up to that of a hazel- 
nut, presenting for the most part an opaque buff-color, often mottled 
with black points or patches ; and exhibiting a cheesy aspect and con- 
sistence, which are modified by the greater or less abundance of fibroid 
material which invests and permeates them. Sometimes, again, but 
much more rarely, there are found, lying between organs which are 
adherent, tubercular laminae of considerable thickness and extent. Peri- 
toneal tubercles, indeed, rarely exist independently of the effusion of 
lymph and the presence of false membranes. The larger tubercular 
masses are usually comparatively few in number ; the miliary tubercles, 
on the other hand, are as a rule thickly set and innumerable. Further, 
in the latter case the peritoneal surface is often found covered with a 
layer of grayish, transparent, adherent, and toughish lymph, which 
not only invests the abdominal organs, but renders them more or less 
mutually adherent, and in the substance of which tubercles are dissemi- 
nated as opaque grains. 

In association with the presence of tubercles all the usual phenomena 
and sequelae of simple inflammation, such as streaky redness, fibrinous 
effusion, and dropsical accumulation, are apt to manifest themselves ; 
sometimes, also, suppuration, sometimes profuse haemorrhage. Further, 
it occasionally happens that, during the progress of peritoneal tubercu- 
losis involving the intestinal walls, perforation of these latter takes 
place. The most important of these phenomena from its frequency is 
undoubtedly ascitic effusion. 

The abdominal lymphatic glands are a frequent seat of tubercle; 
mainly, however, the glands of the mesentery, and more especially 
those of them which are in relation with that portion of the small intes- 
tine which is most commonly tuberculous. Tubercle of these organs 
is mostly secondary to tubercle either of the intestines or of the peri- 
toneum. It appears in them and for the most part in their peripheral 
portions in the form of minute, hard, gray points, which occur in groups 
and tend gradually to run together, and to form imbedded masses which 
soon undergo the caseous change. Glands thus affected may suppurate 
and may even rupture into the peritoneal cavity ; or they may become 
slowly converted into mortary or calcareous lumps. Tubercular glands 
are usually more or less enlarged, sometimes, indeed, attain the size of 
a pigeon's egg. When, however, they undergo the calcareous change 
they contract and become invested with an indurated capsule. Tuber- 
cular mesenteric glands sometimes, especially in children, collectively 
form masses easily detectable through the abdominal walls ; but there 
is little doubt that most of those cases of extreme enlargement of these 



ABDOMINAL PHTHISIS. 



645 



glands which were formerly regarded as tubercular were specimens of 
lymphadenoma or other forms of malignant disease. 

Symptoms and Progress. — 1. Boicels— The symptoms of tubercular 
ulceration of the mucous membrane are in no degree specific; but they 
vary according to the part of the bowel which happens to be affected. 
When the disease is limited to the ileum there will probably be more 
or less pain and tenderness in the region of the caecum and its neigh- 
borhood, with frequent griping. The bowels may be confined or loose, 
but are more frequently, perhaps, irregular. When the large intestine 
is involved, the symptoms closely resemble those of chronic dysentery, 
and, indeed, are by no means necessarily distinguishable from them. 
The points of chief clinical importance in reference to intestinal tuber- 
culosis are : first, that the disease is for the most part a progressive one, 
and that hence diarrhoea having once declared itself tends to become 
progressively more and more severe and intractable; second, that dur- 
ing its progress the patient rapidly undergoes extreme emaciation, be- 
comes excessively feeble, and suffers in an aggravated form from night 
sweats, imperfect circulation (indicated by blueness of nose and cold- 
ness of extremities), and the other phenomena which follow rapid im- 
pairment of nutrition ; and, third, that it is usually associated with 
well-marked indications of tubercular disease in other organs. Haemor- 
rhage, perforation, and stricture are not special to tubercular ulceration, 
and their symptoms need not be now discussed. 

2. Peritoneum. — The symptoms which attend the progress of perito- 
neal tuberculosis present much variety and are often vague and indefi- 
nite. Often, indeed, and not only in those cases in which the peritoneal 
affection is slight, or in those in which it is as it were overshadowed by 
the preponderance of disease in other parts, but in those cases in which 
it is the predominant or sole affection, they fail to indicate clearly the 
peritoneum as the seat of disease. Further, they are so generally com- 
plicated with the symptoms due to coexisting tubercular disease in 
other organs, especially the lungs, pleurae, and intestines, that it is im- 
possible altogether to dissociate them from these latter. Most cases, 
however, of tubercular peritonitis, attended with obvious symptoms, 
may perhaps be somewhat roughly arranged in two classes : the first 
(the acute class), in which the symptoms have a close resemblance to 
those of enteric fever; the second (the chronic class), in which the 
symptoms correspond for the most part with those of chronic peritonitis. 

In the acute form the patient, sometimes in the midst of perfect 
health, more often, however, after some indefinite period of languor 
and loss of flesh and strength, begins to manifest febrile symptoms 
attended with remissions, and indicated by heat and dryness of surface, 
quickened pulse, pains in the limbs, loins, and head, diminution of the 
secretions, and perhaps drowsiness. At the same time probably the 
abdomen becomes somewhat hard, tumid, and tender, and more or less 
uneasy or painful. Generally, also, there is some disturbance of the 
digestive functions — dryness or furring of the tongue, thirst, loss of 
appetite, and nausea or sickness — with probably constipation or diar- 
rhoea, or even alternations of these conditions. And possibly, with no 
material change in his symptoms beyond what may be due to increasing 



646 



DISEASES OF THE DIGESTIVE ORGANS. 



debility and emaciation, and the gradual supervention of "typhoid 
symptoms," the patient gradually sinks, and at the end of a few weeks 
dies. Among the chief points by which this affection may be distin- 
guished from enteric fever are the absence of rash and of pain specially 
limited to the csecal region, the probable presence of tubercular disease 
in other organs, and the fact that the temperature, although it may be 
considerably elevated, does not present that regularity of morning 
remissions and evening exacerbations which are so characteristic of en- 
teric fever. 

In the chronic variety of peritoneal tuberculosis, the disease some- 
times commences with more or less typical symptoms of acute perito- 
nitis ; sometimes it creeps on with the utmost insidiousness ; but in 
either case the symptoms gradually merge into those of chronic perito- 
nitis, with which (unless our diagnosis be aided by the discovery of 
tubercular disease elsewhere) we cannot well avoid confounding them. 
Ascites is very apt to ensue. The duration of chronic tubercular peri- 
tonitis may vary from a month or six weeks to a year or two. 

There is no doubt that tubercular peritonitis tends, as a rule, to a 
fatal result ; at the same time, there are good grounds for the belief 
that recovery occasionally ensues. 

Treatment. — The general treatment of abdominal tuberculosis is 
identical with that of pulmonary phthisis and generally of scrofulous 
disease. It comprises careful attention to hygiene, removal if need be 
to a more suitable climate, a good wholesome and nutritious dietary, 
and the use of cod-liver oil, iron, and vegetable tonics. If the mucous 
membrane of the bowels be specially affected, and the patient be suffer- 
ing from exhausting diarrhoea, treatment must of course be specially 
directed to relieve this condition. For the details of treatment in this 
case we must refer the reader to the articles on intestinal ulceration and 
on dysentery. When the peritoneum is the part principally involved, 
abdominal pain may need to be relieved by the application of counter- 
irritants, or fomentations, or even leeches ; sleeplessness, weariness, and 
pain may require to be overcome by the use of opiates or other forms 
of sedative or narcotic medicines; and further, nausea, sickness, diar- 
rhoea, and intestinal obstruction may all in turn call for relief by the 
various measures on which reliance is in such conditions usually placed. 



MORBID GROWTHS. 

Non-malignant Growths. 

These are not uncommon, but on the whole are of little medical im- 
portance. Pedunculated fibrous outgrowths or polypi are sometimes very 
small, very numerous, and of wide distribution throughout both the 
small and the large intestines. Sometimes, on the other hand, they are 
few in number or solitary, and then often attain large dimensions. 
These latter are occasionally observed in the ileum, but chiefly affect 



MORBID GROWTHS. 



647 



the lower part of the rectum. In the former situation they are believed 
to be in some cases the determining cause of intussusception ; in the 
latter they often produce irritation with bleeding, tenesmus, and other 
discomforts. Those only can be diagnosed and treated which are within 
reach, and for them removal is the only effectual remedy. 

Villous growths are in many cases malignant. Some, however, and 
especially such as are met with in the large intestine, appear to be non- 
malignant. These usually occupy a limited and well-defined area, and 
sometimes encircle the bowel. The intestinal walls in the situation of 
the growth, and especially the mucous and submucous coats are usually 
much thickened; and from this thickened area as a base, close-set, 
elongated, complex villi take their origin. These growths frequently 
cause hemorrhage, which is occasionally serious, and diarrhoea, which 
is sometimes of a dysenteric character. When situated near the anus 
they may be removed by operation. 

Malignant Growths. 

Morbid Anatomy. — Malignant growths commence sometimes in the 
mucous membrane of the stomach or intestines, sometimes in the peri- 
toneal tissue, sometimes in the mesenteric or retro-peritoneal glands. 
In the first case the disease usually takes its origin at some particular 
spot, whence it spreads over a greater or less extent of the contiguous 
mucous membrane, then gradually involves the whole thickness of the 
parietes, and, having reached the serous lamina, diffuses itself in a 
greater or less degree over it, and further implicates the mesenteric or 
other glands. In the second case the growth tends rapidly to gener- 
alize itself over the surface of the serous membrane, and to infiltrate 
the subserous tissue, but it is often a considerable time before it pene- 
trates the muscular wall of the stomach or bowels. Sooner or later, 
however, this becomes invaded at points, and then the mucous mem- 
brane becomes involved. The lymphatic glands necessarily also suffer. 
When the disease begins in the mesenteric or retro-peritoneal glands, 
these gradually enlarge, and presently the morbid growth extends 
from them into the surrounding connective tissue, infiltrates it, and 
thence spreads to the serous membrane on the one hand, and to the 
intestinal walls on the other. It will thus be seen that, although the 
site in which malignant disease commences exerts a more or less im- 
portant influence over its distribution and consequences, the ultimate 
tendency is in each case to bring about almost identical structural 
results. 

1. Scirrhus cancer, originating in the walls of the stomach or bowels, 
causes thickening and induration of the tissue in which it commences. 

If it attack the submucous tissue, this becomes greatly hypertrophied, 
and presently the superjacent mucous membrane is incorporated with 
the growth, the natural structure of this membrane gradually disap- 
pears, and its free surface, at first perhaps thrown into rigid folds, be- 
comes irregular and nodulated. Whilst this process is going on, the 
muscular wall becomes invaded, the morbid growth extends along the 
intermuscular septa, converting them into irregular but thick vertical 



648 



DISEASES OF THE DIGESTIVE ORGANS. 



scirrhous bandstand the muscular tissue itself divided thus into strands 
becomes at first hypertrophied, and subsequently undergoes fatty de- 
generation. At length the subserous and serous tissues are implicated, 
they, like the mucous tissue, become dense, hard, and thickened, and 
the free surface studded with small wheal-like excrescences or nodules. 
Sooner or later in the progress of the case erosion and destruction of 
the affected mucous surface takes place, and a smooth excavated ulcer 
results ; in some cases sloughs form, and the destruction is more rapid 
and irregular, and in some cases again carcinomatous nodules sprout 
up from the edges and floor of the ulcerated surface. Sooner or later, 
also, adhesions form between the affected viscus and neighboring organs, 
and along them the morbid process may be propagated. 

Peritoneal scirrhus always commences in the form of hard, lenticular 
white spots, measuring a line or so in diameter, which, though project- 
ing above the surface, tend specially to invade the subserous tissue. 
They are in the first instance scattered thinly or irregularly, but soon 
become aggregated in parts or generally, and then coalesce so as to 
form patches of various extent. These may be smooth on the surface, 
or may still present traces of the mode in which they were developed. 
They rarely, however, form outgrowths, and not very often invade 
subjacent organs ; rarely, too, do they become more than a line or two 
thick, except when they involve folds or processes of peritoneum. The 
appendices epiploicse become converted into small hard lumps, the 
mesenteric and other like duplicatures thickened and indurated, and 
the great omentum contracted into a thick band, stretching transversely 
across the abdomen in the course of the transverse colon. Scirrhus 
cancer, indeed, whether affecting the gastro-intestinal tube or the peri- 
toneum, tends rather to cause contraction and thickening than out- 
growths, and thus, as a rule, leads to constriction of the cavities or 
canals which it involves, and especially, therefore, to constriction of 
the cardiac or pyloric orifice, or of other parts of the intestinal tube. 

2. Colloid cancer most commonly takes its origin in the serous 
lamina, whence it spreads to the mucous membrane. When appear- 
ing first in the latter tissue, it causes, as other forms of cancer do, more 
or less considerable thickening, and manifests itself at the surface in 
the form of scattered masses, which have either a resemblance to the 
wheals of urticaria, or to groups of herpetic or eczematous vesicles. 
Like scirrhus it invades the muscular coat, running along the inter- 
muscular septa, and causing the muscular tissue to become thickened 
and hypertrophied, then attacks the subserous tissue and the serous 
membrane itself, causing these also to become thickened, and finally 
produces at the free surface groups of vesicles, varying perhaps indi- 
vidually from the size of mustard seeds down to scarcely visible points. 
At the mucous surface the affected patches become eroded and more 
or less deeply excavated, but remain pretty smooth, and discharge in 
abundance the transparent glairy fluid with which the interstices of its 
matrix are filled. Colloid cancer of the peritoneum, in its early stage, 
appears in the form of groups of vesicles, which become more or less 
elevated above the general surface, and spread sometimes in tortuous 
and anastomosing lines as though taking the course of the lymphatic 



MORBID GROWTHS. 



649 



vessels, sometimes by forming scattered, isolated, more or less pedun- 
culated growths. The morbid process tends to spread both in surface 
and in depth. It always involves the subperitoneal tissue, which may 
attain in consequence very considerable thickness, and it extends thence 
most frequently to the muscular and mucous coats of the stomach and 
intestines, less frequently to the substance of the mesenteric glands, 
pancreas, liver, spleen, and other viscera. In extreme cases nearly the 
whole of the peritoneum is affected ; it is then irregularly thickened, 
the various duplicatures become especially hypertrophied, and the 
great omentum either converted into a large lobulated mass, or con- 
tracted, as it is in scirrhus, into a thick, irregular, transverse band. In 
the progress of the disease erosion of the surface is apt to take place, 
and the glairy fluid which it yields is discharged in some abundance 
into the abdominal cavity. 

3. Encephaloid cancer, when affecting the abdominal organs, is char- 
acterized, as it is elsewhere, by its softness, milkiness, and rapidity of 
growth. If it commence in or beneath the mucous membrane, it on 
the one hand soon invades the mucous and submucous tissues, and on 
the other spreads to the muscular coat, and through this to the tissues 
on the outer aspect of the viscus. The extension of the growth both in 
thickness and in surface is usually very rapid, and before long results 
in the formation of a more or less lobulated tumor, which often attains 
a very considerable bulk. The encephaloid mass is of course liable to 
undergo all those interstitial changes to which encephaloid cancer is 
usually liable ; but it tends also to become ulcerated on its mucous 
aspect. Ulceration begins, as a rule, early, and is almost invariably 
attended with more or less abundant sloughing of the cancerous mass, 
which becomes consequently deeply and irregularly excavated. But 
while ulceration is going on, the edges of the ulcerated chasm still 
furnish lobulated outgrowths, and moreover such outgrowths not un- 
frequently take place from the ulcerated surface itself. In some cases 
encephaloid tumors give rise to the development from their mucous 
aspect of a pile of highly vascular villous outgrowths, constituting the 
so-called " villous cancer." Encephaloid cancer of the peritoneum 
appears in the form of discrete nodular outgrowths, which are small 
and rounded, and differ from those of scirrhus not only in their greater 
softness but also in their greater prominence. They are often indeed 
hemispherical, or spherical, or pyriform and distinctly pedunculated. 
In its further progress encephaloid cancer presents great varieties. In 
some cases it seems, like scirrhus, to invade more particularly the sub- 
stance of the peritoneal folds and to involve subjacent organs ; and 
under such circumstances we find the mesentery sometimes converted 
into a thick, plicated, cancerous mass, with the cancerous growth ex- 
tending from the mesenteric attachment over the surface of the intes- 
tines • or we find the greater or lesser omentum or the subperitoneal 
tissue of other regions affected in like manner and forming a more or 
less distinct tumor. In other cases it tends rather to form outgrowths 
which are sometimes small and clustered, sometimes more or less dis- 
tinct from one another, rounded, and massive. In the former instance 
the whole peritoneal surface may be found beset with small lobulated 



650 



DISEASES OF THE DIGESTIVE ORGANS. 



or bunch-of-currant-like excrescences, and the great omentum converted 
into a large loose mass of such bodies. In the latter instance the 
tumors, though more or less abundant, are isolated, and while many 
probably are small, others attain the size of an orange, or even of a 
child's head. So far as we know, the melanotic variety of encephaloid 
cancer always manifests itself in the latter form. 

4. Epithelioma affects the rectum and anus exclusively, in which it 
is sometimes of primary origin, sometimes due to extension from the 
uterus or vagina. The growths here present the same characters as 
are presented by the epitheliomatous growths of the mouth, oesophagus, 
and skin. 

5. Adenoid cancer, or cylindrical epithelioma, which has a close 
resemblance to encephaloid, is not uncommon in the intestine. It is 
probably more common than any as a primary disease of the mucous 
membrane, and is especially apt to cause stricture. 

6. Sarcomatous and Jymphadenomatous growths may be regarded 
clinically as mere varieties of encephaloid cancer. Still they present 
some peculiarities of habit. Sarcomatous growths are exceedingly un- 
common, and arise mainly in the substance of the walls of the stomach, 
where they constitute tumors of considerable size, which tend more or 
less rapidly to ulcerate, and comport themselves generally as do enceph- 
aloid tumors. Lymphadenoma is especially a disease of the lymphatic 
glands and lymphatic textures ; and hence when the abdominal organs 
are its seat, the abdominal glands usually reach an enormous volume, 
and the spleen undergoes more or less considerable enlargement. In 
its further progress the morbid growth involves the connective tissue 
around the already diseased glands ; and hence the substance of the 
mesentery and other similar folds of the peritoneum become thickened 
and infiltrated, and nodular outgrowths sometimes appear upon their 
surfaces. As the affection still progresses the morbid growth creeps 
from the mesenteric attachment on to and around the small intestine, 
confining itself almost, if not quite exclusively, to the peritoneal mem- 
brane and subperitoneal tissue; and thus the intestine, while still re- 
maining pervious and probably quite healthy as to its mucous mem- 
brane, becomes converted into a thickish rigid cylinder. The large 
intestine and even the stomach may be similarly affected. 

Whenever carcinoma or any other form of malignant disease affects 
the peritoneum, stomach, or bowels, it may spread by continuity to 
almost any neighboring organ ; and hence the liver, pancreas, and spleen 
are liable to become invaded when the stomach or peritoneum in the 
vicinity is its seat, and the various pelvic organs when the rectum is 
diseased ; and further, the mesenteric and retro-peritoneal lymphatic 
glands, or some of them, when secondarily affected, often develop into 
large tumors. Such tumors are most rapidly produced, and attain 
their largest dimensions, when the disease to which they are secondary 
is some soft form of malignant disease. 

There are certain parts of the gastro-intestinal tube which are more 
liable than others to be the seat of the primary origin of the various 
forms of malignant disease which have been considered. They are the 
stomach and certain tracts of the large intestine. Of these the stomach 



MORBID GROWTHS. 



651 



is much the most frequently affected; and, although no portion of its 
surface enjoys absolute immunity, there is no doubt that its pyloric 
extremity most frequently suffers. When the cardiac orifice is the 
seat of disease, the adjoining portion of the oesophagus is commonly 
affected. When the pylorus suffers, the morbid process usually encircles 
that portion of the stomach which adjoins it, but very rarely indeed 
extends into the duodenum. The effect of malignant disease upon the 
stomach is in many cases to cause irregular contraction and deformity, 
and especially to cause stricture at the cardiac or the pyloric orifice. 
If the pylorus be alone affected and resist the onward transmission of 
food, the stomach often becomes preternatural ly dilated ; if, on the other 
hand, there be impediment to the entrance of food from the oesophagus, 
the organ necessarily shrinks. Of the large intestine, the parts .most 
liable to suffer primarily are: first, the rectum, and second, the sigmoid 
flexure; and here, as at the orifices of the stomach, the disease tends to 
circumscribe the tube and to cause stricture. It may be added that 
while all parts of the gastro-intestinal canal are apt to be implicated in 
the progress of malignant disease commencing in the peritoneum or the 
lymphatic glands, the lower part of the rectum is especially liable to 
become involved in the extension of uterine, vaginal, or other pelvic 
growths. Further, it must not be forgotten that malignant disease, 
whether of the stomach or bowels, may be attended with rupture into 
the peritoneal cavity or with the establishment of communications with 
adjoining hollow organs ; that hemorrhage (sometimes profuse), with 
foul or fetid discharges, is apt to take place from the congested or ulce- 
rated mucous surface ; and that (especially when the peritoneum is 
largely involved) peritoneal inflammation, or ascites, or obstruction to 
the return of blood from the lower extremities, frequently supervenes. 

Of the various forms of maligant disease affecting the organs under 
consideration, scirrhus is undoubtedly the most common; scarcely any 
of them, however, is absolutely rare. Taking all forms together, it 
may be said that, they mostly occur after the age of forty — a rule, how- 
ever, which is more absolute as regards the primary stomachal or in- 
testinal disease than that of the peritoneum ; indeed malignant disease 
(especially in connection with similar affection of the ovaries) is not 
uncommon in young adult females. Sex, on the whole, exerts but 
little influence. Carcinoma of the stomach is one of the most fre- 
quently fatal forms of malignant disease. 

Symptoms and Progress. — The symptoms referable to malignant 
disease of the several organs now under review simulate those of the 
inflammatory (mainly chronic) affections of the same organs which 
have already been discussed. And the differential diagnosis between 
them depends therefore less on the presence or absence of specific symp- 
toms than on a careful consideration of the history of the case, and on 
a close observance of the phenomena which it presents, and their rela- 
tion to one another. Thus malignant disease of the stomach has many 
features in common with chronic gastritis and gastric ulcer; malignant 
disease of the bowels many in common with chronic ulceration of the 
bowels and its various sequela?; and malignant disease of the peritoneum 
many in common with chronic peritonitis, tubercular peritonitis, and, 



652 



DISEASES OF THE DIGESTIVE ORGANS. 



we may add, simple ascites. But malignant disease is always remark- 
ably insiduous in its progress, and vague symptoms of ill-health, with 
loss of flesh and strength, usually manifest themselves long before the 
patient quite recognizes the fact that he is ill, or can quite define the 
character of his sufferings. The patient is therefore, generally ill and 
often markedly cachectic before the specific signs of stomachal, intes- 
tinal, or peritoneal mischief reveal themselves. Again, the course of a 
case of malignant disease is always progressively from bad to worse; 
and this progressively downward tendency is connected as a rule not 
simply with the aggravation of the ordinary symptoms due to progres- 
sive impairment of function of the organ primarily affected, but to the 
supervention of complications connected with the special properties of 
malignant disease, such as the involvement of the liver and other 
abdominal organs in the morbid growth, and the development of dis- 
ease in more remote organs. The appearance of a tumor and its mani- 
fest increase in bulk and change" in form, in association with the va- 
rious characteristics above enumerated, leave little room for doubt. 
Febrile symptoms, thirst, and dryness or foulness of tongue are no nec- 
essary accompaniments of the disease. 

1. Stomach. — The special symptoms due to the presence of malig- 
nant disease of the stomach are as various as those of ordinary dys- 
pepsia. They comprise mainly loss or capriciousness of appetite, pain, 
and vomiting. Anorexia is a very constant and ordinarily a very early 
symptom; it is, however, very variable in its presence, and is sometimes 
absent from first to last. Occasionally the appetite is excessive. Uneasy 
feelings, weight, and fulness, in the region of the stomach, are frequently 
complained of, especially after taking food. In most cases also there is 
absolute pain of a more or less intense character, variously described as 
aching, burning, cutting, or stabbing, and referred either to the epigas- 
trium or the interscapular region or to other neighboring situations. 
This conies on in paroxysms, which are probably at first " few and far 
between," but increase in frequency, duration,, and severity with the 
progress of the disease. It is often brought on or increased by the in- 
gestion of food, or by pressure applied to the epigastrium. Pain, how- 
ever, like anorexia, is sometimes of little severity, and occasionally 
wholly wanting. Eructation is a common but unimportant symptom. 
Vomiting, however, supervenes sooner or later in the great majority of 
cases. This is mostly caused by the taking of food, and comes on at 
different periods after it ; if the cardiac orifice be contracted the food is 
usually returned at once (as in other forms of oesophageal obstruction) 
by regurgitation ; if the pylorus be affected the vomiting is often de- 
layed for an hour or two or more than that ; when the stomach is very 
irritable vomiting may (as in gastric inflammation) take place almost 
immediately after the food has entered the stomach. The vomited 
matters in the earlier periods of the disease are chiefly altered ingesta 
combined with mucus and the acid secretions of the stomach. Later 
on (especially if ulceration have taken place) small quantities of blood 
escape from the diseased surface, and, mingling with the contents of 
the stomach, give to the vomited matters a sooty or coffee-ground ap- 
pearance. The persistence indeed of this kind of vomit is very char- 



MORBID GROWTHS. 



653 



aeteristie of gastric carcinoma. Profuse discharge of blood, with hsem- 
atemesis and melaena, occasionally takes place, but is not nearly so fre- 
quent relatively as it is in cases of simple ulcer. When sloughing 
occurs, the vomited matters are often extremely offensive. It is very 
common, especially when the pylorus is the seat of disease, for them 
to contain sareince or the torula cerevisice. The detection of a tumor in 
malignant disease of the stomach depends partly on its size and partly 
on its situation. A tumor at the cardiac orifice or cardiac extremity 
can rarely be felt, however large or extensive it may be ; and one situ- 
ated in the posterior wall or lesser curvature is less easy of recognition 
than one occupying the anterior surface or the larger curvature or the 
pylorus. The situation of such tumors varies somewhat. They mostly, 
however, occupy the epigastric or right hypochondriac region, but are 
sometimes found in the neighborhood of the umbilicus. Unless they 
become firmly adherent to the abdominal walls in front, or have blended 
with the pancreas or other enlarged glands behind, they are usually 
movable to some extent under the abdominal walls, both during the 
act of forced inspiration and (if the patient is lying down) in rotation 
of the body from side to side. They are often somewhat irregular in 
shape, are generally very hard, and not unfrequently lifted up with 
the aortic pulsations. They are usually also resonant on percussion. 
Constipation is almost invariably present. The special symptoms 
which ensue when rupture of the stomach into the peritoneal cavity 
takes place, or when a communication becomes established with the 
transverse colon need not be detailed. 

2. Bowels. — The symptoms referable to malignant disease of the 
bowels are yet more vague in their indications than those which attend 
gastric carcinoma. There is generally more or less irregularity of ac- 
tion, sometimes looseness, sometimes constipation, and it may be the 
occasional discharge of mucus or modified blood. At the same time 
there is often pain, partly of a colicky character and connected with 
unwonted movements of certain portions of the bowels; partly burning, 
aching, or cutting, and referable to some particular region. Malignant 
disease of the large intestine, however, and more particularly that of 
the sigmoid flexure and rectum, produce as a rule more or less impedi- 
ment to the action of the bowels, and finally more or less complete 
stricture. It is in this particular case also that, associated with symp- 
toms of obstruction — preceding them, accompanying them, or follow- 
ing them — mucous sanguinolent, purulent, and fetid discharges, occa- 
sionally even profuse haemorrhages occur. Further, if the rectum be 
the seat of disease, the case in its progress is apt to be complicated 
by the formation of communication between the bowel on the one hand, 
and the vagina, bladder, or urethra on the other. But in malignant 
disease of the bowels, equally as in malignant disease of the stomach, 
the presence of a distinct permanent tumor is a fact of capital importance. 
This may often fail of recognition ; moreover phantom tumors, due to 
accumulation of flatus or of faeces, are in such cases especially apt to 
arise and disappear from time to time and puzzle the physician. When 
the lower part of the rectum is affected, the presence of a tumor may 
generally be readily detected by digital examination. 



654 



DISEASES OF THE DIGESTIVE ORGANS. 



3. Peritoneum and Glands. — The symptoms of peritoneal and of 
glandular malignant disease are necessarily very various and easy to 
be misunderstood. These affections are in a very large proportion of 
cases associated with similar disease of the stomach, bowels, liver, 
uterus, or ovaries, and not unfrequently supervene upon them ; and 
hence their special symptoms are liable to be confounded with and 
masked by those of the latter lesions. On the other hand, many of the 
symptoms commonly attributed to malignant disease of the stomach 
and other abdominal organs are strictly referable to involvement of the 
peritoneum and lymphatic glands. Among the symptoms which at- 
tend the affections now under discussion must be enumerated nausea, 
vomiting, loss of appetite and constipation, diarrhoea, or irregularity of 
the bowels, together with more or less abdominal uneasiness and pain. 
The most significant point, however, is the progressive enlargement of 
the belly with the presence of a growing tumor or of tumors. These 
present all varieties of character ; they may occur in any region ; may 
be movable or fixed ; may vary in size or shape ; may be hard and re- 
sisting, or soft and almost yielding a sense of fluctuation ; and especi- 
ally when they are developed in the neighborhood of the coeliac axis 
and superior mesenteric artery or over the aorta, may pulsate as dis- 
tinctly as many aneurisms do. And hence, notwithstanding the im- 
portant evidence which their presence furnishes, they may be con- 
founded, at some stage at least of their progress, with circumscribed 
abscesses, hydatid tumors, floating kidneys, or even aneurisms. In 
cases where (even if the malignant disease is very extensive) the indi- 
vidual tumors are small, the presence of peritoneal outgrowths may 
altogether escape detection. It is worth while to draw attention to the 
fact that not unfrequently, when no other signs of tumor are distinguish- 
able, the presence of the thickened and contracted great omentum, 
which has been shown to occur frequently in scirrhous and in colloid 
cancer, may be recognized as a more or less irregular transverse bar ex- 
tending horizontally from under the margins of the left ribs across the 
upper part of the umbilical region to the neighborhood of the umbili- 
cus. To the above statement it must be added that the peritoneal affec- 
tion frequently becomes complicated by ascites or by peritonitis of a 
subacute character, or by involvement of the gastro-hepatic omentum 
with obstruction of the vena portae, or of the common bile-duct and 
consequent jaundice, or by anasarca of the lower extremities ; and that 
occasionally also the kidneys become affected, the ureters obstructed, 
or the various pelvic organs involved. 

Treatment. — The treatment of the above affections can unfortunately 
be palliative only. When symptoms are chiefly referable to the stomach 
they must be treated, and may for a time be benefited, by adopting the 
measures which have been recommended for the treatment of gastric 
ulcer. When the intestines are mainly involved, diarrhoea may need 
to be restrained by astringent medicines, constipation to be overcome by 
mild laxatives, such as castor oil and the like, or by enemata. And 
pain, whatever its seat or source, may often be relieved by counter- 
irritation, fomentations, or leeches. Opium in such cases is generally 
invaluable, and in most cases becomes at length indispensable, relieving 
discomfort and pain, soothing the mind, and giving sleep. The patient 



TAPEWORMS. 



655 



should of course be sustained by appropriate aliment in sufficient quan- 
j tities and, if necessary, by stimulants. The quality of the food and the 
mode of its administration must be determined by the special require- 
ments of the case ; but generally it may be said that it should be whole- 
some, easily digestible, and administered in small quantities and at 
frequent intervals. Milk, eggs, beef tea, broths, fish, and the like are 
among the most suitable articles of diet. 



PARASITIC AFFECTIONS. 

Tapeworms and Cystworms. (Cestoda or Tceniada.) General 

Account. 

The general term cestoda or taeniada includes tapeworms and cyst- 
worms. Of these a large number of species are known to exist; but 
four only of them are of interest and importance to the practical phy- 
sician. They are the taenia solium, the taenia mediocanellata, the tenia 
echinococcus, and the bothriocephalic latus, with their respective cystic 
representatives. 

All the tseniada pass through two phases of existence. In the one 
the characteristic head or scolex of the animal, developed in connection 
with a cyst or bladder-like body, and devoid of sexual organs, lies 
imbedded in the solid tissues of the host, or creature that harbors it. In 
the other the animal, or rather colony of animals, in the form of a tape- 
worm or strobilus, occupies the alimentary canal. In this condition it 
still presents at its upper extremity a scolex or head by which it adheres 
to the mucous membrane, while its tape-like body is divided into a 
series of quadrilateral elements, or proglottides, each of which when 
mature contains male and female organs and must be regarded as a 
distinct animal. To trace the cycle of events in the life-history of the 
tseniada it will be convenient to commence with the ripe proglottides. 
Within these are produced enormous numbers of fertile eggs, in the in- 
terior of each one of which a peculiar six-hooked embryo is developed. 
These proglottides usually become detached from the rest of the strobilus, 
escape from the anus of the host, and either then or previously discharge 
their ova, which become scattered broadcast. Of these fertile ova some 
find their way sooner or later into the alimentary canal of some appro- 
priate animal. Then the six-hooked embryo bursts its shell, migrates 
through the intestinal parietes, and continues its wanderings until it 
reaches some spot suitable for its further development, where it gradu- 
ally undergoes those changes which result in the formation of the 
perfect cystic scolex. The further fate of this scolex depends mainly 
on that of its host. It cannot migrate, but lies passive in the cavity 
which it has formed for itself, and there at length perishes, unless be- 
fore that event its host becomes the prey of some other animal. Under 
these last circumstances the scolex enters the alimentary canal, and 
under the new conditions which then surround it at once enters on a 



656 



DISEASES OF THE DIGESTIVE ORGANS. 



new career of life. It fixes itself to the mucous surface, it loses its 
vesicular expansion, and from its caudal extremity the strobilus or 
chain of sexually reproductive proglottides is gradually evolved. Thus 
two distinct hosts are as a rule needed for the completion of the cycle 
of existence of these creatures; the one (usually a vegetable-feeder) for 
the asexual period of its existence, the other (very commonly carniv- 
orous animal) for the period of its sexual activity. It follows from the 
above statements that the ova of the tapeworm, even if set free within 
the alimentary canal, probably never become hatched until after their 
escape from thence. Further, it may be regarded as a general rule, 
that the same species of animal is not liable to suffer from both the 
cystic and the sexual forms of the same cestode. Man is in some degree 
an exception to this rule, for he is apt to harbor both the taenia solium 
and its vesicular representative, the cysticercus cellulose. Looking, 
however, to the fact that patients affected with this tapeworm are not 
usually also affected with the cysticercus, and conversely, and that man, 
moreover, is an omniverous feeder, there is good reason to believe that 
the exception is apparent rather than real, and that he derives the two 
forms of the parasite in the orthodox way from independent sources. 

Taenia Solium, Taenia llediocanellata, and Bothriocejihalus Latus. 

1. Taenia Solium. — Cysticercus Cellulosce. — The taenia solium is one 
of the most common of human tapeworms. In its perfect condition it 
usually measures from seven to ten feet long, but often exceeds that 
length. Its head or scolex, which is about as large as a small pin's 
head, or, to be more exact, between ^ and g * F inch in diameter, is 
succeeded by a delicate thread-like neck, which, gradually becoming 
broader and flatter and wrinkled transversely, merges ere long in the 
distinctly-jointed body. The joints or proglottides are, in the first 
instance, much broader than they are long; but gradually with their 
increase in size this relation ceases; and although they still get broader, 
their length throughout the greater part of the strobilus exceeds their 
breadth. Towards the lower extremity, the quadrilateral joints measure 
on the average a quarter of an inch wide by half an inch long. The 
globose head presents four projecting suctorial disks placed at equal 
distances upon and a little above the equator ; and springing from its 
pole a rounded elevation, or rostcllum, the margin of which is furnished 
with a double circle of hooks. The apparently homogeneous neck may 
be seen under the microscope to be transversely wrinkled at a very 
short distance from the head. The sexual apparatus first becomes visi- 
ble about a foot below the head. It comprises male and female organs 
opening in each joint by a common aperture, situated in the lateral 
edge — the apertures of the successive proglottides alternately occupying 
opposite sides. At about two feet from the head the ova become im- 
pregnated, and shortly afterwards enter the uterus, which occupies a 
large portion of the body of the proglottis, forming a longitudinal cen- 
tral canal with several horizontal diverticula on either side. The eggs 
are globular, about inch in diameter, present a remarkably thick 



TAPEWORMS. 



657 



brownish shell, both concentrically and radially striated, and when ripe 
contain a six-hooped embryo. 

The taenia solium is essentially an inhabitant of the small intestine, 
to the mucous surface of which it fixes itself by its hooklets and suck- 
ers. It is usually, as its name implies, solitary; but two, three, or 
more are not unfrequently associated, and occasionally much larger 
numbers. From the time of its entrance into the bowel until it reaches 
its full development a period of three and four months usually inter- 
venes ; and it may live in the bowel for many years, during which 
time it is constantly shedding its ripe proglottides and discharging ova 
into the alimentary canal. 

The cysticercus cettulosce is chiefly known as a denizen of the flesh of 
pigs, in which it is sometimes present in vast numbers, rendering the 
pork " measly." And it is almost exclusively to the use of such pork 
in an uncooked or an imperfectly cooked condition that the develop- 
ment of taenia solium in the human intestine is due. In the compara- 
tively rare cases in which the cysticercus has been found in the human 
body it has affected the muscles, the connective tissue, the brain, the 
eye, or the serous membranes. It exists under the form of a round or 
ovoid vesicle, about the size of a pea or bean, but sometimes attaining 
that of a marble, formed of a transparent elastic membrane containing 
a clear limpid fluid. Springing from one side of this vesicle is a 
wrinkled cylindrical neck, terminating in a head precisely similar to 
that of the taenia solium. The neck and head protrude externally after 
death, and may be made to protrude by pressure during life ; but in 
the ordinary living state they are retracted within the vesicle, lying 
coiled up against one side of it. The conversion of the six-hooked em- 
bryo into the perfect cystic scolex occupies about two and a half months; 
and the scolex may remain living in the tissues of its host for many 
years. 

2. Tcenia Mediocanellata — Cysticercus Tcenice m. c. — This tape- worm, 
which was formerly confounded with the last, is equally common. It 
presents a general resemblance to it both anatomically and in habit ; 
but it presents also characteristic differences. It attains a greater 
length, its joints are longer and broader, and its head also is about 
three times as thick. The head, moreover, is furnished with four large 
round pigmented suckers, but with neither rostellum nor armature of 
hooklets ; the uterus, though exhibiting the same general arrangement 
as that of the taenia solium, is characterized by much more numerous 
and finer transverse processes ; and the ova, instead of being round, 
are oval, the long diameter differing little from the diameter of the egg 
of the taenia solium, the short diameter measuring about H J-q inch. 

The cysticercus of this tape-worm seems especially to affect the ox, 
and it is, therefore, to the eating of imperfectly-cooked beef that the 
introduction of the scolex into the intestines is due. The cysticercus 
is a small oval vesicle, similar to that of the cysticercus cellulosae, but 
smaller than it, and furnished with a neck and head, of which the 
latter is identical with that of the adult sexual strobilus. It is not 
known to affect the human being. 

42 



658 



DISEASES OF THE DIGESTIVE ORGANS. 



3. Bothriocephalus Lotus. — This tape-worm is limited in its range 
to certain European countries, especially to Belgium, Holland, Poland, 
Prussia, Russia, Sweden, and Switzerland. It is the largest of all 
tape-worms, not ^infrequently attaining a length of twenty-five feet 
and upwards, and often measuring more than half an inch in width at 
its widest part. The head is ovoid in form, measuring about T \ inch 
in length by 5 J g in breadth, and presenting two opposite longitudinal 
deep grooves or suckers, but no hooklets. The neck, which is com- 
paratively narrow, soon becomes transversely wrinkled ; and as it 
widens out and retreats from the head, these wrinkles divide it into 
successive segments. The segments gradually increase in all their 
dimensions, but for the most part continue of greater width than length ; 
and are specially characterized, not merely by their general form, but 
by the facts that the genital pore is placed in the centre of each flat 
surface, and that the uterus forms a small rosette, of which this pore 
is the centre. The ova never become matured within the uterus, and 
usually escape thence into the bowel, while the proglottis is still a por- 
tion of the strobilus. After the discharge of their ova, the joints 
diminish in size, and become shrivelled and elongated. The eggs are 
of oval form, measuring about 3^ inch by 5^0? anc ^ have a firm 
brown shell, which opens by a lid at one end. The embryo, on its 
escape from the egg, is provided with cilia, which it soon loses, and 
then presents the common six-hooked character.. The cysticercus of 
this tape-worm is at present unknown ; it is also unknown where it 
takes up its abode. It is generally believed to inhabit some fish or 
other aquatic animal. 

Symptoms. — The symptoms to which tape-worms give rise are on 
the whole trivial and unimportant. Many of those who are infested 
by them enjoy perfectly good health, and many more make them the 
scapegoats of all their ailments (imaginary or otherwise) from which 
they happen to suffer during the residence of these parasites within 
them. Among the symptoms which are referred to their presence are I 
pain and discomfort in the belly, variable appetite, variable condition 
of bowels, itching at the nose and anus, depression of spirits, emacia- 
tion, and hysterical, epileptic, or other nervous phenomena. The list 
might easily be extended ; but when we consider that, notwithstanding 
all the evil influences which have been attributed to them, they are 
probably never diagnosed or even suspected to be present until their 
joints have been detected in the stools, it is obvious how vague and on 
the whole how apocryphal all these influences are. The only way, in- 
deed, in which the presence of tape-worms can be recognized is by the 
discovery of their joints either in the stools or about the anus or on the 
body-linen, and of their eggs by the microscopic examination of the 
faeces. 

The cysticercus cellulosse causes no symptoms unless it be lodged in 
some delicate or vital organ, such as the eye or cortex of the brain, and 
then the symptoms are not specific. 

Treatment. — Many remedies have been employed for the purpose of 
getting rid of tape-worm ; but those on which reliance is now chiefly 
placed are the male fern, the bark of the pomegranate root, kousso and 



HYDATIDS. 



659 



kamala. The liquid extract of male fern may be administered in a 
dose of from 30 to 120 minims early in the morning on an empty 
stomach, and be followed shortly by a full dose of castor oil. And if 
this procedure prove insufficient, the treatment may be repeated either 
on the next day or from time to time at short intervals. The other 
varieties of vermifuge are employed in much the same manner. The 
decoction of pomegranate root is given in large quantities, a pint or 
more, for example, in two or three portions at short intervals. Kousso 
is administered similarly, excepting that the powder from which the 
infusion is made is usually drunk with the infusion. The dose of this 
is from four to eight ounces. These drugs rarely fail to bring away 
large portions of the worm ; but no absolute cure has been effected, 
unless the head is brought away as. well. This, however, from its 
small size is very apt to escape detection. It is consequently of great 
importance to make a very careful inspection of the evacuations which 
are passed subsequently to the administration of vermifuge drugs. In 
order to prevent the development of tape-worms in the intestine, it is 
necessary that flesh, and especially those kinds of flesh which are 
known to harbor their vesicular representatives, should always be eaten 
in a well-cooked condition. Underdone and merely smoke-dried beef 
and pork should certainly be avoided. 

With respect to the cysticercus cellulose, unless it occupies some 
superficial part, and thus lies within reach of surgical treatment, we 
can do nothing for the patient's relief. The ova of the taenia solium 
are probably taken into the stomach with uncooked vegetables, salads, 
and the like, and hence those who wish to guard against them should 
content themselves with cooked vegetables only. 

Tcenia Ecliinococcus. Hydatid. 

The tcenia ecliinococcus is only known to affect the dog and wolf, 
and is usually found in them in large numbers, adhering to the mucous 
membrane of the duodenum and jejunum. It is peculiar in comprising 
in its perfect form four joints only, and in having a length of little 
more than a quarter of an inch. The first joint is that which includes 
the head. This measures about t Jq inch wide, and is furnished with 
four suckers, and a central rostellum, provided w T ith a double coronet 
of hooklets, which vary from thirty to forty in number. The fourth 
segment, which is as long as the other three joints together, is usually 
alone furnished with sexual organs and a marginal reproductive papilla. 
The eggs, like those of the taenia solium, are globular and thick-walled. 

The cysticercus or larval form of this tape-worm, commonly known 
as an hydatid, is one of the most dangerous to life of all parasites. It 
differs from the cysticerci of other tape- worms in the facts that it is, on 
the one hand, capable of almost indefinite increase of size, on the other 
capable of almost indefinite multiplication by the formation of gemmae. 
Its favorite haunt is the liver, next to that the subperitoneal tissue, and 
then probably the lungs, kidneys, and brain. It is found also in the 
heart, muscles, and bones ; and indeed has occasionally been detected 
in almost every organ and tissue of the body. In its early condition 



660 



DISEASES OF THE DIGESTIVE ORGANS. 



it is a small globular cyst, with transparent laminated walls and finely 
granular contents. At a later stage the cyst has acquired considerable 
dimensions, the walls have become thick and the contents fluid. The 
walls are formed of two portions: an outer, comparatively thick, which 
is transparent, elastic, tremulous, and beautifully laminated ; an inner, 
which is thin, delicate, and composed mainly of delicate cells, often 
containing oval or globular refractive bodies. The fluid contents are 
limpid, colorless, of low specific gravity, and peculiar in containing a 
considerable quantity of salt, and, as a rule, no albumen. In some 
cases the hydatid experiences no other change than an increase of size. 
Much more commonly, however, it undergoes further development. 
This consists principally in the formation of other cysts in the sub- 
stance of its walls, sometimes towards the outer aspect, sometimes in 
the mid-region, sometimes towards the inner aspect, and then often in 
connection with the cellular lamina. These secondary cysts in many 
cases repeat in their growth all the characters of the parent hydatid. 
In many they remain permanently devoid of the outer laminated wall. 
But whether they continue thus simple or not, and especially in the 
former case, their contents often undergo gradual conversion into one 
or several echinococci or scolex heads — the cysts then forming what 
are sometimes termed brood-capsules, and remaining permanently of 
minute, if not microscopic size. The results of these processes going 
on almost indefinitely are very various. Thus, in some cases an hyda- 
tid tumor as large, perhaps, as a child's head, consists of one hydatid 
cyst only, with a larger or smaller number of brood-capsules, spring- 
ing bud-like from its inner surface; in other cases an indefinite pro- 
duction of barren hydatid cysts takes place, so that the original cyst 
becomes filled with innumerable daughter cysts, each of which has, 
like its parent, the capacity for growth and the production of new cysts 
by gemmation ; in other cases again (and these are the most common) 
the parent hydatid ultimately contains both barren and fertile cysts. 
It occasionally happens that the hydatids formed in the walls of the 
primary cyst, instead of projecting at its inner surface, and finally be- 
coming shed into its cavity, project outwards and thus form separate 
tumors ; and further, that in the liver the hydatid growth forms a 
multilocular mass, in which it may be assumed that the walls of the 
separate cysts are, as it were, fused together. 

The scolox or echinococcus in its living condition is a rounded or 
ovoid body, from yi^ to q 1 g inch in length, attached by a depression at 
one extremity to a cord which fixes it to the wall of the brood-capsule, 
and presenting at the other extremity an orifice communicating with a 
central vertical canal, at the bottom of which lie the retracted rostellum 
and hooklets, and on the sides of which are seated the inverted suctorial 
region. When the animal is dead all the latter organs are protruded, 
and the form which it then presents is as nearly as possible that of the 
first joint of the taenia ; the small vesicular body is surmounted by a 
kind of quadrilateral expansion, the angles of which are occupied by 
suckers and from the centre of which arise the rostellum and the crown 
of hooklets. These latter vary in length between y^go an( ^ sio i ncn - 
The growth of hydatids is for the most part very slow; they enjoy, 



ROUND WORMS. 



661 



however, a long life, often continuing to grow and multiply for five, 
ten, fifteen years or more, and it may be during the whole period of 
the life (however much prolonged) of their host. They do, however 
(like all other imbedded parasites), in many cases undergo spontaneous 
dissolution ; in which case the tumors shrink ; the cyst walls become 
flattened and compressed against one another ; the echinococci break 
down, shedding their hooklets; the surrounding tissues become thick- 
ened and indurated; and an abundant deposition of calcareous matter 
pervades the capsule and even the hydatid mass. 

For the symptoms and treatment of hydatid tumors we must refer to 
the diseases of the several organs in which they occur. We need only 
mention here that no drug that we know of given by the mouth is 
capable of affecting these creatures injuriously; and that, in reference 
to prophylaxis, the chief if not sole source from whence we derive them 
is the excrement of dogs. 

Bound Worms. (Ncematoda.) 
General Account. 

These are elongated round worms, presenting a distinct integument 
marked with fine transverse rugae, a perivisceral cavity, a distinct ali- 
mentary canal, provided with a mouth at one extremity, and for the 
most part an anus on the ventral aspect close to the opposite extremity, 
and sexual organs. The sexes are always separate; in the male (which 
is smaller than the female) the genital pore opens in immediate relation 
with the anus ; in the female, the vaginal orifice is usually situated 
about the middle of the ventral aspect. 

It is certain that some species of this sub-class of parasites need (like 
the tamiada) two successive hosts for the completion of their cycle of 
existence. The trichina spiralis, for example, passes an asexual life 
imbedded in the voluntary muscles of the pig or man ; and there, unless 
the affected flesh become the food of some other animal, after awhile 
they die. If, however, the trichinous flesh be eaten, the cysts in which 
the trichinae are contained become dissolved ; the animals are set free, 
rapidly acquire sexual organs and copulate ; ova are developed and fer- 
tilized and hatched while still in the uterus ; and the living embryos 
on their birth, instead of remaining in the bowel, undergo an active 
migration through its walls, and ere long reach the tissues in which 
they are to become imbedded. As regards the ascaris lumbricoides, 
there is good reason to believe not only that the ova which are shed in 
vast numbers into the intestinal canal which they occupy are never 
hatched there; but that they are taken into the body of some other 
animal, probably one of the invertebrata, within which (possibly im- 
bedded in the parenchyma) they complete one phase of their existence. 
There is reason even to doubt whether the common thread-worms mul- 
tiply in the region which they infest — whether the ova which they dis- 
charge so abundantly becomes hatched within the anus. Dr. Ransom 
indeed suggests that in many cases (among young children especially) 
there may be a kind of reinfection due to the conveyance of the ova 
from the anus to the mouth by means of the fingers. 



662 



DISEASES OF THE DIGESTIVE ORGANS. 



Among the nematode worms are included the Ascaris lumbricoides, 
the Oxyuris vermicularis, the Dochmius duodenalis, the Trichocephcdus 
dispar, and the Trichina spiralis, which will now engage our attention; 
the Filaria medinensis, whose effects are surgical ; and several others, 
including the Strongylus gigas, which are of rare or doubtful occurrence 
in man, and have consequently little practical interest. 

Common Round Worm. (Ascaris Lumbricoides.) 

This well-known worm varies in size : in the female from 10 to 14 
inches long, and from J to J inch thick ; and in the male from 4 to 6 
inches long, with a correspondingly small diameter. The worm is 
cylindrical, tapering to either end, white with a brownish or reddish 
tinge, and invested in a firm elastic integument. The ova, of which 
each female discharges, on the average, 160,000 daily, are oval, meas- 
uring gi n inch by T Jg inch. They have a thick, firm, nodulated 
shell, and contain, as ordinarily passed from the bowel, no trace of 
embryo. 

This ascaris is found in some few animals besides man. In man its 
special habitat is the small intestine, but it is apt to wander, and thus 
to reach the colon on the one hand, or the stomach on the other ; and, 
indeed, it has been known to find its way into the hepatic or pancreatic 
duct, and also into the nose or larynx. It has been often asserted that 
it occasionally perforates the wall of the bowel, thus finding its way 
into the peritoneum or into some sinus or abscess. It is now, however, 
generally held that when found in such situations it has simply passed 
thither through an accidental perforation. The number of ascarides 
present at the same time rarely exceeds five or six. But authentic 
cases are on record in which the bowels have been infested with hun- 
dreds and even thousands of them. The length of time during which 
a worm remains a denizen of the bowels is probably never more than 
a few months. 

Symptoms. — Innumerable symptoms have been referred to the pres- 
ence of these parasites, as to that of the taeniae, but there is no doubt 
that in the great majority of cases they give no indication whatever of 
their presence, wmich is not even suspected until one or more have been 
discharged. The symptoms which might reasonably be referred to 
them are those of intestinal irritation, which, in children, are always 
liable to be attended with some degree of fever and more or less cere- 
bral disturbance. When these worms are harbored in large numbers 
there is no doubt that they may induce very grave gastro-enteritic 
symptoms, but symptoms which are in no sense characteristic. Occa- 
sionally too a mass of them causes complete occlusion of the bowel, as 
any other concretion may do. In all cases where these w r orms are sus- 
pected to be present, and always before a cure can be safely announced, 
the faeces should be subjected to microscopic examination, when, if they 
be present, the innumerable eggs which are discharged can scarcely be 
overlooked. Ascarides are occasionally vomited. 

Treatment. — Various remedies have been employed with the object 
of getting rid of ascarides, and among them those which are in common 



SEAT - WORM — WHIP -WORM. 



663 



use against tape-worms. The mucuna pruriens also was formerly much 
esteemed. The remedy now mainly relied upon is santonica, and more 
especially its active principle, santonin, of which from one to three 
grains may be given twice daily to a child, and about twice that quan- 
tity to an adult. Violent purgatives are of little or no use ; an occa- 
sional laxative may, however, be given with advantage during the 
course of treatment by santonin. 

Common Thread-worm or 8eat-worm. (Oxyuris Vermicular is.) 

This creature is minute, fusiform, white, and, as its popular name 
implies, thread-like. The female varies from J to J inch in length, 
and presents a comparatively long attenuated caudal extremity. The 
male is about half the length of the female, and its caudal extremity 
is simply fusiform. The ova are oval, but unsymmetrical, measuring 
inch by y,^. They present a firm shell with three laminae, of 
which one is absent at one of the poles. At the time of deposition 
they contain a developing embryo. Thread-worms are probably the 
most common of all intestinal parasites; they infest persons of all 
ages, but children much more frequently than adults. They occur 
habitually in the colon alone, and indeed are limited almost exclusively 
to the rectum. They are often present in enormous numbers. The 
females are apt to migrate through the anus, and to deposit their eggs 
on the skin and among the hairs in its vicinity; they occasionally also 
find their way into the vulva, vagina, and urethra. 

Symptoms. — The chief symptom to which oxyurides give rise is 
troublesome itching about the anus, coming on mainly in the evening; 
it is often intolerable, especially if they have migrated into the vulva 
or urethra. Children affected with them are said also to suffer from 
itching at the nose; and many of the functional disturbances which 
have been attributed to the presence of more formidable parasites have 
also been attributed to them. The diagnosis of thread-worms can 
easily be verified by their discovery and that of their ova in the faeces. 

Treatment. — Local measures are usually amply sufficient for getting 
rid of thread-worms. The injection of a strong infusion of green tea, 
quassia, or any other bitter, or of a solution of perchloride of iron or 
salt, repeated if need be from time to time, is usually efficacious ; the 
use of mercurial ointments or other parasiticide applications in and 
around the anus may be serviceable for the destruction of the ova in 
these situations ; in addition to which measures occasional purgatives 
may be administered, and the patient put under a course of tonics. 

Whip-worm. (Trichocephalus Dispar.) 

This is said to be not uncommon. It is, however, rarely met with 
in this country. It is especially characterized by having a compara- 
tively thick cylindrical body, terminating anteriorly in a delicate fili- 
form process, which forms about two-thirds of the entire length of the 
parasite. The male measures about one and a half inch long, and the 
female about two inches. The latter is very prolific. The eggs are 



664 



DISEASES OF THE DIGESTIVE ORGANS. 



oval, about inch by jfao, pointed at either end, and presenting a 
firm brownish-yellow shell. The normal habitat of this worm appears 
to be the csecum, to which it attaches itself by burying its threadlike 
neck in the substance of the mucous membrane. 

It does not appear to give rise to any symptoms, and, indeed, its 
presence can only be diagnosed by the discovery of ova in the faeces. 

No treatment is needed ; the measures most likely, however, to be 
efficacious in effecting its dislodgment are those already discussed in 
relation to the ascaris. 

Dochmius Duodenalis. (Sclerostoma Duodenale.) 

This is a small cylindrical worm of which the female slightly exceeds 
half an inch in length; the male is somewhat smaller. It has not been 
met with in this country, but is not uncommon in hot climates. The 
inhabitants of Italy and Egypt are especially liable to be infested with 
it. It appears to take up its abode in the duodenum and upper part of 
the jejunum, where it may be present in vast numbers, fixing itself 
to the villi, sucking the blood thence, and causing haemorrhages and 
dangerous (sometimes fatal) anaemia. 

No efficacious treatment is known. The measures recommended for 
the expulsion of the ascaris may, however, be tried. 

Trichina Spiralis. Trichinosis. 

The trichina spiralis was known only as an occasional inhabitant of 
the muscular tissue, in which it was now and then discovered acci- 
dentally, and was regarded as a mere pathological curiosity, until the 
year 1860 ; when a case that came under the observation of Dr. Zenker, 
of Dresden, conclusively showed that, however harmless the encysted 
parasite might be, the gravest symptoms, and even death itself, might 
be caused, after its reception into the bowels, during the process of 
reproduction which then ensued there, and during that of the migra- 
tion thence of the young animals into the voluntary muscles. Since 
that period the " trichina disease" or " trichinosis" has been fully recog- 
nized and frequently observed. 

The trichina spiralis is met with in the muscular tissue in the form 
of a minute worm, measuring about inch in length. Its anterior 
extremity is somewhat pointed, its posterior thick and rounded; it 
presents immature sexual organs, and lies coiled up in the interior of 
an oval cyst. This cyst which is no essential part of the parasite, but 
forms around it after it lias taken up its quarters, measures about fa 
inch in length, is thick-walled, laminated, transparent, and generally 
studded externally, especially about the poles, with granular calcareous 
matter. The trichina cysts occupy the striped muscles of the body, 
and are often especially abundant in those of the larynx. The heart, 
however, is rarely if ever involved. They appear in the muscles as 
minute white grains distinctly visible to the naked eye, of which the 
long diameter corresponds to the direction of the fibres. Their appa- 
rent size is usually increased by the fact of the development of groups 



TRICHINOSIS. 



665 



of fat-cells in relation with either extremity. The numbers present 
vary, of course, in different cases. In a cat experimented upon by 
Leuckart each ounce of muscle was calculated to contain 325,000 
trichinae; and on the basis of this calculation Dr. Cobbold estimates 
that a man of medium bulk may easily harbor 20,000,000. The 
length of time during which these larval trichinae retain their vitality 
is very uncertain. There is no doubt, however, that they may live in 
the muscular tissue for many years, and that they retain life after the 
death of their host, and even after the putrefaction and disintegration 
of his tissues. They do, however, perish in situ sooner or later, and 
then usually undergo calcareous changes. Trichinae have been discov- 
ered in the flesh of various animals besides man, but mainly in that of 
the pig ; and indeed it is from the use of trichinous pork that man 
becomes affected. The trichina-capsules swallowed with the flesh are 
dissolved by the gastric juice, and the contained parasites are set free. 
These then rapidly undergo development and attain sexual maturity, the 
female ultimately acquiring a length of J inch, the male not more than 
the T ] 8 inch. The ova are hatched within the uterus, and the living 
embryos, escaping thence into the intestinal canal of the host, at once 
commence active migration. They attach themselves to the mucous 
membrane, eat their way through the intestinal walls, and either con- 
tinue to burrow through all the tissues which lie between them and 
their destination, or, what is more probable, find their way into the 
small vessels and lymphatics of the bowels, and are thence conveyed 
by the blood-stream all over the organism. They have been found 
during this period in almost all parts of the body, in the intestinal walls, 
in the abdominal cavity, in the mesentery and mesenteric glands, in 
the connective tissue, and in an as yet unencapsuled condition in the 
muscular tissue itself. 

The progress of events above described is always very rapid. The 
immature trichinae taken into the stomach become mature on the second 
day ; on the sixth and following days, up to the end of the second or 
even third week, the embryos are born and commence operations ; they 
probably reach their destination in the course of a week or two, and 
by the end of a month or a little more have come to the conclusion of 
their labors. 

Symptoms and Progress. — The symptoms which attend the develop- 
ment and migration of trichinae are on the whole very remarkable and 
suggestive of the disease. They comprise, in the first instance, those of 
gastro-intestinal disturbance; in the next those of general muscular 
inflammation ; and associated with these, febrile symptoms of more or 
less severity. 

Within a day or two, or at most a week, after the ingestion of the 
trichinous flesh symptoms not unlike those of enteric fever manifest 
themselves. The patient suffers from thirst and loss of appetite, with 
perhaps nausea and sickness ; and from colicky pains in the abdomen, 
with constipation or irregularity of the bowels, or actual diarrhoea. 
His tongue is coated ; and there is more or less mental and muscular 
prostration, with elevation of temperature, and acceleration of the 
heart's action. These symptoms, which are ill-defined in the beginning, 



666 



DISEASES OF THE DIGESTIVE ORGANS. 



become aggravated day by day during the first week or ten days of the 
patient's illness, and in some cases culminate in those of fatal enteritis 
or peritonitis. More commonly, however, about the end of this time 
they undergo some remission and then gradually subside. But while 
these symptoms are in progress, and even it may be in progress of 
amendment, other symptoms due to the migration of the parasite de- 
velop themselves and soon overshadow them. These consist mainly in 
gradually increasing pain and tenderness, swelling and stiffness of the 
voluntary muscles, together with oedema of the subcutaneous connective 
tissue, copious perspirations, and aggravation of debility and of febrile 
disturbance. The pains have some resemblance to those of rheuma- 
tism, but they occupy the fleshy parts of the limbs and trunk and not 
the joints. The general stiffness, tenderness, and swelling lead to 
flexion and immobility of the limbs, and it may be to impediment to 
the due action of the muscles of the tongue and larynx and of those 
concerned in respiration. Dropsy, which is one of the earliest indica- 
tions of the migration of the parasites, commences in the face, par- 
ticularly in the eyelids, then attacks the extremities, and subsequently 
probably becomes general, involving even the serous cavities. Hoarse- 
ness, or loss of voice, and dyspnoea are not uncommon. The tempera- 
ture presents great differences. In some cases it rarely, if ever, rises 
above the normal. In severe cases, however, it may reach 104°, 105°, 
or even 106°, but then varies greatly and irregularly from day to day, 
and always preconsiderable morning remissions. 

The total duration of symptoms varies. In mild cases the patient 
recovers in the course of a month ; in many cases recovery is delayed 
to the end of six weeks or two months ; and occasionally the patient 
continues ill for three or even four months. There is no doubt that 
the trichinous disease varies very greatly in severity, and that its 
severity depends mainly on the number of living parasites which the 
patient receives into his bowels. In some instances there are few or 
no symptoms to attract attention ; in some outbreaks where many per- 
sons have been attacked the mortality has been very light; while in 
others the death-rate has been twenty or twenty-five per cent. Death 
may result from enteritis, peritonitis, or pneumonia, or from the de- 
bility which the progress of the disease gradually induces ; and may 
occur at any time between the fifth or sixth day and the end of the 
sixth week. 

The presence of trichinosis in its acute stage may possibly be con- 
firmed by the discovery of parasites in the intestinal discharges, or by 
the extraction by means of a suitable instrument (harpoon) of fragments 
of striped muscular tissue. The under part of the tongue has been 
specially recommended for exploration. ~No symptoms attend the 
presence of the encapsuled parasites in the muscles. The diseases with 
which trichinosis is most liable to be confounded are enteric fever, 
acute tuberculosis, and acute rheumatism; but the distinctions between 
it and them are obvious. 

Treatment. — We have not, so far as is known, any power to destroy 
trichina?, whether in the intestines or in the substance of the living 
frame. It is of course possible that remedies useful against other in- 



OBSTRUCTION OF THE STOMACH. 



667 



testinal parasites may be useful against these, supposing their presence 
to be detected sufficiently early to justify us in attempting to dislodge 
them. As a general rule, we can only treat trichinosis on the same 
principle as we treat other affections made up of local inflammatory 
conditions and general fever. We can, however, employ prophylactic 
measures, and these are, fortunately, sufficiently simple. They consist 
in the avoidance of pork which presents the characteristic appearances 
of the disease, and especially of pork which is not well and completely 
cooked. The mere toasting to which ham and bacon are frequently 
subjected is insufficient to destroy the vitality of the trichina. Smoked 
ham and German sausages are, unless they have been cooked, sources 
of considerable danger. It is mainly in Germany, where pork raw, 
smoke-dried, or imperfectly cooked, is a common article of diet, that 
trichinosis is known to occur. 



DEGENERATIVE AFFECTIONS OF THE STOMACH 
AND BOWELS. 

Degenerative changes of the mucous membrane play, no doubt, an 
important part in the various chronic disturbances of the stomach and 
bowels, to which the terms dyspepsia, diarrhoea, and the like are 
usually applied. They follow upon chronic inflammation and other 
persistent lesions of the alimentary mucous membrane, and occasion- 
ally depend on the presence of certain forms of cachexia?. They com- 
prise mainly fatty degeneration and wasting of the glands, associated 
either with general atrophy of the mucous membrane or with increased 
development of fibroid tissue; and lardaceous change. Lardaceous 
degeneration affects the small intestine much more frequently than the 
stomach or the large intestine, and probably never occurs except in 
association with advanced lardaceous disease of the liver, spleen, or 
kidneys. The villi chiefly suffer. 

The symptoms referable to the various forms of degeneration do not 
at present admit of identification. 



OBSTRUCTION OF THE STOMACH. 

Causation and Morbid Anatomy. — Many of the morbid conditions 
which have already been described involve more or less serious impedi- 
ment to the due performance of the mechanical functions of the stomach, 
and consequently to the due transmission of its contents onwards ; and 
indeed the symptoms arising from obstruction form an important part 
of their clinical history. 

Obstruction occurs chiefly at the pyloric and cardiac orifices ; it may, 
however, arise in some intermediate part. It is due sometimes to mere 
fibroid thickening or cirrhosis ; sometimes to malignant disease ; some- 



668 



DISEASES OF THE DIGESTIVE ORGANS. 



times to the cicatrization of large n leers ; sometimes to the pressure of 
external tumors ■ sometimes to accumulation of hair, cocoanut fibres, 
or other solid matters which have from time to time been swallowed, 
sometimes to paralysis or spasm. 

The consequences of obstruction at the cardiac orifice have already 
been considered under the head of oesophageal disease; they are dila- 
tation and hypertrophy of the oesophagus, and contraction and atrophy 
of the stomach. In pyloric obstruction the food which is received into 
the stomach tends to accumulate within it, and thus to lead to its dila- 
tation and hypertrophy. The dilatation under such circumstances is 
sometimes enormous. If the impediment occupy some intermediate 
position, its influence over the form and functions of the stomach will, 
according to circumstances, approximate more or less either to that of 
cardiac or to that of pyloric obstruction. In some cases habitual star- 
vation tends to cause more or less permanent general contraction of 
the stomach ; in some cases habitual overeating or accidental and ill- 
understood conditions involve extreme dilatation of the organ ; both 
of which states are apt to be attended with many of the phenomena of 
pyloric stricture. 

Symptoms and Progress. — The symptoms of cardiac obstruction are, 
mainly, ability to perform the act of deglutition, and in rapid succes- 
sion to this act more or less uneasiness, referable to the situation of the 
cardiac orifice, and the rejection of the matters swallowed by a process 
which has more resemblance to eructation than to vomiting. The 
patient probably has a good appetite, but cannot gratify it, and suffers 
from all the usual symptoms of starvation. In most cases the ob- 
struction is partial only, and more or less food finds its way into the 
stomach. In some the retention of food in the dilated oesophagus 
lasts for a considerable time, and the retained matters prior to their 
rejection undergo putrefaction or fermentation, and become mixed with 
mucus secreted from the surface of the tube. The epigastric region 
shrinks, owing to the necessary contraction of the starved stomach. 

The symptoms referable to obstructive disease of the pylorus are, in 
many important respects, different from the above. The patient can 
swallow with ease, and everything that is swallowed finds its way with- 
out difficulty into the stomach ; from whence (according to the degree 
of impediment present) it is in part transmitted more or less slowly 
onwards, in part, after awhile (it may be half an hour, an hour, seve- 
ral hours, occasionally even several days), and after having caused 
more or less gastric uneasiness, rejected by vomiting. The characters 
of the vomited matters largely depend upon the length of time during 
which they have been retained. If they be discharged shortly a^ter 
ingestion they consist mainly of partially digested food mingled with 
the normal secretions of the stomach ; if after a long interval they 
have generally undergone putrefactive or fermentative changes, are 
more or less fetid, abnormally acid, and probably contain sarcinse or 
the yeast fungus, or both. Their quantity varies considerably, and 
sometimes amounts to several pints. The appetite is more likely to 
suffer in pyloric than in cardiac obstruction, but is not unfrequently 
retained. The dilatation of the stomach which attends this affection 



OBSTRUCTION OF THE STOMACH. 



669 



reveals itself locally by more or less distension of those parts of the 
abdominal surface with which the organ lies in contact, and probably 
by displacement of the diaphragm upwards. If it be moderate it 
causes more or less fulness of the epigastric region only; if it be con- 
siderable, the body of the organ descends, forming a loop between the 
pyloric and cardiac orifices, and the chief distension then probably oc- 
cupies the umbilical and hypochondriac regions, the epigastrium pre- 
senting a comparative depression. In some cases the dilated stomach 
occupies nearly the whole of the anterior part of the abdomen. That 
the distension is due to the stomach is shown partly by its situation, 
partly (if it be considerable) by its looped form, partly by observing 
the peristaltic movements, which are generally easy of recognition 
and admit of being readily excited, and partly by the evidences which 
palpation and percussion give of a large cavity containing air and fluid. 

The symptoms due to general contraction of the stomach are espe- 
cially inability to take food, excepting in small quantities, irritability 
of the organ, and tendency to vomit shortly after the ingestion of food. 
Simple dilatation of the stomach differs little, if at all, in its symptoms 
from incomplete pyloric obstruction. 

In all of the above cases, starvation, emaciation, asthenia, and the 
phenomena which attend these conditions supervene with more or less 
rapidity ; further various complications are apt to arise in their course 
and to prove fatal, among which may be mentioned gastritis and peri- 
tonitis. 

Treatment. — The treatment of obstruction must vary somewhat in 
different cases, in dependence partly on the site of obstruction, partly 
on its cause. If it be at the cardiac orifice, the careful passage of 
bougies may serve to maintain an available passage; and, failing this, 
the question of making an opening into the stomach at the epigas- 
trium and of feeding the patient through this opening, may be enter- 
tained. If it be at the pyloric orifice, or if the case be one of simple 
dilatation, it may become necessary under certain circumstances to 
empty the distended organ by means of the stomach-pump, or to let 
off some of the gaseous accumulation by acupuncture through the ab- 
dominal walls. In all cases it is important to give food in small quan- 
tities at a time, and in the fluid or semifluid condition, in which form 
it most readily passes through a narrowed or strictured orifice. In 
cases of pyloric disease or passive dilatation, it is further important 
that the stomach should not be overburdened with food, and hence 
that this should be administered in a concentrated form ; that putre- 
faction and fermentation should be obviated by the use of appropriate 
remedies, such as creosote and the hyposulphites ; and that tendency to 
vomit and gastric uneasiness should be met by the measures elsewhere 
recommended for these purposes. Lastly, it is often necessary to feed 
the patient per rectum. 



670 



DISEASES OF THE DIGESTIVE ORGANS. 



OBSTRUCTION OF THE BOWELS. 

The affections which are here to be treated of present many features 
in common with enteritis, and their description is not unfrequently in- 
cluded in the description of that disease. Enteritis does indeed occur 
at some period or other in the course of most of them; but their special 
claim to form a group apart consists in the fact of the existence in all 
of them of some mechanical impediment to the transmission of the con- 
tents of the bowels, in connection with which enteritis is apt to, but 
does not necessarily, supervene. They are : stricture, compression and 
traction, internal strangulation, impaction of foreign bodies, and intus- 
susception. It will, however, be convenient to preface our observa- 
tions under these heads with some remarks upon their common factor, 
constipation. 

1 . Constipation. 

Causation, Morbid Anatomy, and Symptoms. — It may doubtless be 
accepted as a general rule that persons enjoying robust health, and un- 
disturbed in the due performance of their various functions, have an 
alvine evacuation at least once daily. Yet many, who at any rate seem 
equally healthy, have their bowels habitually relieved every two or 
three days only, or even but once a week or fortnight. Cases are not 
altogether rare in which some degree of good health has been main- 
tained for many years, although fecal evacuations have during that time 
occurred only at intervals of six weeks or two months. Cases, indeed, 
are on record in which interval between the successive evacuations 
has been extended to a period of three months. In most cases, how- 
ever, retention beyond the usual period is apt to produce not only local 
uneasiness, such as fulness, heat, tendency to piles, and flatulence, but 
also some degree of general disturbance indicated by headache, foul 
breath, loss of appetite and dyspeptic symptoms, and not unfrequently 
ends with the occurrence of more or less tenesmus and even slight 
dysenteric diarrhoea. Habitual constipation is usually attended with 
chronic discomforts of the same kind ; but it leads also to more or less 
permanent hypertrophy and dilatation of the rectum, conditions which 
render this tube less efficient for the performance of its expulsive duties. 
When constipation is of long duration, not only the rectum but the 
w 7 hole of the large intestine may become dilated by its contents and 
hypertrophied, the mucous surface may be fretted into ulceration, and 
perforation may ensue. The dilatation is sometimes so great that the 
colon measures from ten to twelve inches in circumference, the chief dila- 
tation occurring in the rectum, sigmoid flexure, and csecum. The hy- 
pertrophy under such circumstances is general, but it is usually greatest 
in the sigmoid flexure and upper part of the rectum, where the thick- 
ness of the muscular coat may be J- inch or more. 

Constipation depends on various causes. It sometimes arises tem- 
porarily from change of diet, scene, or habits, among which latter may 
be included anything which interferes with the regular performance of 
defecation ; it commonly happens in various kinds of disease, and oc- 



OBSTRUCTION OF THE BOWELS. 



671 



curs in a chronic form in chl orotic or dyspeptic girls and young women, 
and also in persons of sedentary habits or of sluggish constitution. 
Among local conditions which may be supposed to operate in a greater 
or less degree in the above cases are : first, modifications in the char- 
acter of the faeces, such as we see in diabetes, where they become preter- 
naturally dry and proportionately diminished in bulk ; second, sluggish- 
ness or debility on the part of the rectum itself; and, third, affections 
at or in the neighborhood of the anus, rendering defecation painful. 

2. Stricture. 

Causation and Morbid Anatomy. — By this term is meant a circum- 
scribed diminution of the calibre of the bowel. Stricture is sometimes 
due to spasm ; but although spasm undoubtedly forms a very impor- 
tant element in many cases of intestinal obstruction, it is rare as an in- 
dependent affection, and in this form is practically limited to the rectum 
and anus. # Indeed, spasmodic obstruction, even in these situations, is 
probably always secondary to ulceration, excoriation, or morbid sen- 
sitiveness of the mucous membrane. Stricture, in the vast majority of 
cases, is the consequence of some organic change — of cicatrization after 
ulcer, of cirrhosis, or of some adventitious growth (malignant or other) 
occupying the intestinal walls. It rarely follows ulceration unless this 
has been of large extent, or has encircled the bowel. It rarely if ever 
ensues on the cicatrization of typhoid ulcers, and not very often on the 
healing of tubercular ulcers. It is a much more common consequence 
of dysenteric or syphilitic ulceration and of the separation of a portion 
of bowel in intussusception. But most frequently the ulcer to which it 
is traceable has, so far as we know, no specific or ascertainable origin. 
Cicatricial stricture may form a mere ring or may occupy the bowel for 
several inches of its length. The surface is sometimes completely cic- 
atrized; sometimes presents still unhealed spots of ulceration, with fun- 
gous excrescences or granulations ; and is often separated from the sub- 
jacent muscular coat by a more or less abundant formation of dense 
fibroid tissue. Stricture, again, especially in the low r er part of the rec- 
tum, is sometimes connected with the progress of chronic inflammatory 
changes or the overgrowth of fibroid tissue, not only in the walls 
of the rectum itself, but in the surrounding connective tissue of the 
pelvis. But by far the most frequent cause of stricture is the develop- 
ment of carcinoma in the substance of the intestinal walls. When car- 
cinoma causes stricture or serious obstruction, it is for the most part a 
primary growth at the seat of stricture, and, like simple ulcer, some- 
times forms a mere ring round the gut, sometimes involves a compara- 
tively large area. Congenital stricture or occlusion of the bowel is 
mainly an affection of the anus or rectum, or both, and falls therefore 
especially under the cognizance of the surgeon. It has, however, been 
occasionally met with in the duodenum, in the neighborhood of the 
orifice of the common bile-duct. 

The presence of a stricture always leads, in a greater or less degree, 
to certain results. These are : first, undue accumulation of fseces in 
the bowel above, with proportionate dilatation of its tube; second, 



672 



DISEASES OF THE DIGESTIVE ORGANS. 



hypertrophy of the muscular walls of the dilated bowel ; and third, 
diminution in calibre, and even atrophy, of the bowel below. It is 
an interesting fact that, in stricture of the colon, the greatest degree of 
dilatation is often found, not in the portion of bowel immediately 
above the stricture, but in the caecum. The tighter or longer the stric- 
ture, the more marked, other things being equal, will be the several 
consequences just named, and the more danger will there be of the 
supervention of permanent obstruction. Yet it is remarkable that 
tight and long strictures are often found after death in cases in which, 
during life, there had been no suspicion of their presence — a statement 
more particularly true of stricture of the small intestine, in which part 
the contents are, as a rule, semi-fluid and easy of propulsion. The 
lodgment of faeces above a stricture is very apt not only to prevent the 
complete healing of the ulcer to which originally the stricture may 
have been due, but to cause erosion and ulceration in the dilated bowel 
above, and ultimately perforation. 

Stricture may arise anywhere in the bowel, yet it is met with in dif- 
ferent parts with different degrees of frequency. Its occurrence as a 
fatal disease in the small intestine is rare. It is mainly, indeed, a dis- 
ease of the larger bowel. According to Dr. Brinton, out of 100 fatal 
cases of stricture of the large intestine, 4 occur in the caecum, 10 in the 
ascending colon, 11 in the transverse colon, 14 in the descending colon, 
30 in the sigmoid flexure, and 30 in the rectum. It is more frequent 
in. men than in women, and the average age at which it proves fatal is 
a little over forty-four. 

Symptoms and Progress. — The symptoms due to stricture of the 
small intestine are rarely sufficiently definite to justify us in diag- 
nosing its presence. They probably combine nothing beyond occa- 
sional colicky pains, nausea, and sickness. Even in the case of the 
large intestine, they may be for a long time vague and inconclusive, 
and even misleading. The patient perhaps suffers only from occasional 
attacks of colicky pain, associated it may be with more or less consti- 
pation, but not unfrequently, during the earlier period, diarrhoea is a 
prominent symptom. If the stricture be in the lower part of the rec- 
tum, solid motions generally soon assume a narrow tape-like or pipe- 
like form. 

The symptoms of absolute obstruction occasionally come on quite 
suddenly, but are more frequently preceded by more or less long-con- 
tinued tendency to constipation. It sometimes also happens that the 
patient, previous to his final attack, has experienced one or more simi- 
lar attacks, which have yielded to treatment. The symptoms of impas- 
sable stricture are : insuperable constipation ; painful peristalsis, com- 
ing on periodically, and often rendering itself audible by borborygmi, 
and visible through the abdominal walls ; abdominal distension and 
uneasiness, followed after a time by nausea, vomiting, and hiccough ; 
and death at last from simple asthenia. The vomited matters become 
after awhile stercoraceous. Febrile symptoms and abdominal tender- 
ness may be absent from first to last, but sometimes inflammation 
supervenes, or perforation takes place, and then enteritic or peritonitic 
symptoms become superadded. When the case is free from these or 



OBSTRUCTION OF THE BOWELS. 



673 



other complications, its progress is essentially chronic, and the patient, 
if not improperly treated, may live for a considerable time, occasion- 
ally for several weeks. 

In determining the seat of stricture, it is well to recollect that at 
least three-quarters of the strictures of the large intestine are situated 
to the left of the mesial plane of the body. We need not, however, 
rest content with a simple calculation of chances. It is natural to 
believe that the distension of the bowel above the stricture, and its 
collapse below, should reveal themselves to manual, if not to ocular 
examination, and in many cases undoubtedly the form and position of 
a struggling, or even of a quiescent length of distended bowel, may be 
thus readily identified. It must not be forgotten, however, that thick- 
ness or rigidity of the abdominal walls, or tenderness, or the presence 
of tumors, or. the altered positions which greatly distended tracts of 
bowel are apt to assume, often prevent the easy recognition of even 
extreme differences of intestinal dilatation and fulness. Dr. Brinton 
maintains that the amount of fluid which may with care be injected 
per anum is a very valuable guide in estimating, so far as the large 
intestine is concerned, the seat of stricture. This method of investi- 
gation is, however, scarcely trustworthy, unless the stricture be at a 
comparatively small distance from the anus. But when in this latter 
situation, its presence may often be ascertained by the introduction of 
the finger, or even of the entire hand, and if it be beyond the* reach of 
actual touch, yet in the rectum the careful introduction of a bougie 
may possibly reveal its position. 

3. Compression and Traction. 

Causation and Morbid Anatomy. — Under these terms we include 
those cases in which the bowel is obstructed either by pressure exerted 
on it from without, or by being dragged out of its normal position by 
adhesions, without being at the same time strangulated. 

Under this heading may be placed those cases in which the rectum 
is obstructed and defecation rendered painful or difficult by the pres- 
sure of a displaced or enlarged uterus, or of a uterine or ovarian tumor. 
Any abdominal tumor may, conceivably, have a like effect on some 
part or other of the alimentary canal, and even the effused blood from 
a ruptured aneurism may surround and compress the duodenum or 
some part of the colon. But the cases here more particularly referred 
to are those in which obstruction is due to the embarrassment of a 
greater or less length of bowel, caused by the presence on its outer sur- 
face of lymph or false membrane, which binds it more or less firmly to 
the surrounding parts, and sometimes constricts it, sometimes leads to 
the formation of sharp angular bends. In some of these cases the 
bowel has been incarcerated in a hernia, and portions* of it have become 
invested in adhesions which attach it to the neck, or some other part of 
the sac, or to the omentum ; in others, the transverse colon or sigmoid 
flexure, or some other tract of bowel, is hooked down, as it were, by 
bands of lymph to the uterus, or ovary, or some other structure within 
the pelvis ; in others, again, several contiguous coils of small intestine 

43 



674 



DISEASES OF THE DIGESTIVE ORGANS. 



are tightly bound together, forming a kind of tangled mass. Fatal 
cases always furnish distinct evidence of more or less complete obstruc- 
tion, in the contraction and emptiness of the bowel below, and in the 
fulness, dilatation, and hypertrophy of the bowel above. But the 
part in which actual obstruction has taken place, though contracted 
and more or less empty, will frequently admit with ease of the passage 
of the finger, or even of some larger body. The immediate cause of 
obstruction, indeed, is rarely a simple tight constriction. These lesions 
are of far more frequent occurrence in the small intestine than in the 
large, and, as Dr. Fagge points out, may, from the clinical point of 
view, be regarded as the strictures of the smaller bowel. 

Symptoms and Progress. — The symptoms of these affections are 
almost, if not quite, identical with those of stricture. It is impossible, 
indeed, to make any absolute clinical distinction between them. It 
may, however, be well to bear in mind that obstruction in the course 
of the small intestine is as a rule more early followed by vomiting than 
is obstruction of the large intestine ; and that it may in some cases be 
possible, by careful examination of the surface of the abdomen, to 
ascertain whether abnormal distension is due entirely to dilatation of 
the small intestine, or mainly to distension of the colon. 

4. Internal Strangulation. 

Causation and Morbid Anatomy. — This arises from similar causes to 
those which produce ordinary strangulated hernia, namely, constriction 
or nipping of a portion of bowel by the edges of some natural or arti- 
ficial orifice through which it protrudes, with consequent arrest of the 
circulation of blood through it, and impediment to the passage of fecal 
matters along it. Such orifices are the foramen of Winslow, congenital 
or acquired perforations in the mesentery, meso-colon, great omentum, 
or other peritoneal duplicatures, or apertures formed with the aid of 
neighboring parts by bands of fibroid tissue extending from one point 
of the peritoneal surface to another. 

Hernial protrusion through the foramen of Winslow must be exceed- 
ingly rare. Perforation of the various peritoneal duplicatures, with 
passage of bowel through the perforation, is much more common, and 
not unfrequently then the result of laceration from violence. This 
accident is most common in connection with the mesentery; but it 
occurs also in connection with the great omentum, the meso-colon, the 
fold belonging to the vermiform appendix, the suspensory ligament of 
the liver, and the broad ligament of the uterus. There is no part of 
the peritoneal surface to w T hich bands capable of producing strangula- 
tion may not be attached ; but there are certain structures and certain 
conditions of parts with which they are specially apt to be connected. 
Thus the vermiform appendix often adheres to neighboring structures, 
such as the mesentery, small intestine, colon, and ovary, forming a kind 
of loop ; diverticula of the ileum become attached, usually by the apex, 
to the mesentery or some other adjoining part, or are prolonged to the 
umbilicus by a cord — a remnant of foetal life. Again, bands producing 
strangulation are often connected with the mesentery or with the parts 



OBSTRUCTION OF THE BOWELS. 



675 



concerned in old ruptures, or with the pelvic organs, and more particu- 
larly the uterus, Fallopian tubes, and ovaries. It may further be noted 
that strangulation occasionally results from the slipping of a loop of in- 
testine under the lower edge of the unusually elongated mesentery of a 
portion of bowel hanging low into the pelvis, or under the pedicle of 
an ovarian or uterine tumor. Finally, there are rare cases of internal 
strangulation in which the bowel protrudes into a lacerated bladder, 
uterus, vagina, or bowel, or through a congenital communication be- 
tween the peritoneum, on the one hand, and the pericardium or one of 
the pleurae on the other. 

The small intestine is much more frequently strangulated than the 
large, and of the large intestine the parts most liable to this accident 
are those which are most freely movable, especially the sigmoid flexure 
and the caecum. Internal strangulation occurs at any age, but generally 
above thirty. It seems, however, that strangulation from bands con- 
nected with the vermiform appendix and diverticula are most common 
at a comparatively early age. 

The symptoms of internal strangulation are identical with those of 
ordinary strangulated hernia, and so like those which have been already 
described as the symptoms of the severer forms of enteritis that there is 
no need to give here any special account of them. 

5. Impaction of Foreign Bodies. 

Causation and Morbid Anatomy. — The ordinary intestinal contents, 
no matter how undigestible, how unwholesome, or how imperfectly com- 
minuted the ingesta from which they are derived may be, very rarely 
indeed cause by their accumulation permanent intestinal obstruction ; 
yet it is doubtless the fact that undigested masses of food do sometimes 
in their passage along the small intestine move with difficulty or be- 
come temporarily impacted and so produce pain and sickness and 
even symptoms of obstruction. Hard foreign bodies of comparatively 
small size — coins, bits of bone, teeth, marbles, plum-stones, and the 
like — generally traverse the intestine without causing inconvenience; • 
and occasionally sharp bodies, such as pins, prove equally innocuous. 
They are all, however, a source of danger, especially in the presence of 
strictures, above which they are apt to become lodged; or from the 
fact that they may slip into diverticula or into the vermiform appendix, 
or (if they be hard and pointed) that they may perforate the intestinal 
wall, and cause, according to the seat of perforation, fatal peritonitis or 
circumscribed abscess, or fistula. Further, an accumulation of such 
bodies, for example a large number of cherry-stones, may become welded 
into a mass sufficiently bulky to obstruct fatally a perfectly healthy 
bowel. Insoluble matters in the form of powders or of fibres, when 
habitually swallowed even in small quantities, are often found to be- 
come concreted into hard masses. These sometimes are round or oval, 
and may then be termed intestinal calculi, sometimes form hollow casts 
of the portion of gut in which they lie. The former are probably 
always found in the large intestine; the latter rarely, if ever, occupy 
any other position than the rectum. Among the substances here refer- 



676 



DISEASES OF THE DIGESTIVE ORGANS. 



red to are peroxide of iron, carbonate of magnesia, imperfectly cooked 
starch, and oat-hairs derived from articles of food made from oats. 
Among cases of exceptional rarity must be named those of persons who 
have been in the habit of swallowing knives, pins, string, hair, or 
cocoanut fibres. These substances are generally found accumulated 
either in the stomach or upper part of the small intestine, and when 
fibrous usually become felted and form masses which take the shape of 
the cavity in which they lie. 

But the usual cause of fatal impaction, and that with which we have 
more especially now to do, is the escape of biliary concretions from the 
gall-bladder into the small intestine. The concretions here referred to 
are single stones or masses of coherent stones of considerable bulk, 
varying at a rough estimate from three to four inches in circumference, 
and from one inch to two, three, or even four in length. It is obvious 
that concretions of this magnitude can scarcely escape from the gall- 
bladder per vias naturales ; and indeed there is little doubt that their 
discharge is in all cases effected through an ulcerated opening between 
the gall-bladder and the duodenum. When such a body has got into 
the duodenum it is carried on with the other contents of the bowel by 
the ordinary peristaltic movements. But its mere bulk prevents it 
from moving readily; besides which it provokes by its shape and size 
and hardness some irritation if not inflammation in the mucous surface 
over Avhich it passes, and more or less spasmodic contraction of the 
muscular tissue which surrounds it. It hence continues its progress 
fitfully onwards, until finally it becomes permanently arrested, some- 
times in the jejunum, but more commonly in the ileum, and not un- 
frequently in its narrowest part, just above the ileo-csecal valve. Then 
all the effects of complete obstruction, conjoined with those of intense 
enteritis, supervene ; the bowel below becomes empty, that above dis- 
tended and generally more or less inflamed ; while at the seat of ob- 
struction and in its immediate neighborhood the inflammation becomes 
intense, speedily extends to the peritoneal surface, and not rarely ends 
in gangrene and in perforation. Gallstones seldom if ever become 
lodged in any part of the large intestine, and when large ones are found 
there they have probably gained an entrance by an ulcerated com- 
munication between the gall-bladder and transverse colon. Gallstones 
are a product of the later period of life ; and hence obstruction from 
gallstones can only be looked for in advanced age. It occurs, indeed, 
rarely before the age of fifty, and much more frequently in women than 
in men. 

Symptoms and Progress. — The symptoms due to the impaction of 
gallstones are as nearly as possible identical with those of internal 
strangulation or enteritis. These cases are, however, amongst the most 
violent in their symptoms and the most rapid in their course of all 
cases of intestinal obstruction. Dr. Brinton calculates their average 
duration at five days. A clue to the nature of the case may sometimes 
be furnished by the occurrence of precursory symptoms due to the 
passage of the calculus along the bowel, and by the detection of the 
hard mass itself in transitu. The age and sex of the patient are also 



OBSTRUCTION OF THE BOWELS. 



677 



suggestive. There is not necessarily or even generally in these cases 
any history of hepatic colic or other indication of hepatic affection. 

6. Intussusception. 

Causation and Morbid Anatomy. — By this term is meant the descent 
or prolapse of a portion of the bowel into the lumen of the bowel which 
immediately succeeds it and is continuous with it. As the result of 
this accident we find the normal course of the intestine interrupted by 
a kind of knot, in which three successive lengths of tube lie almost 
concentrically one within the other, the innermost consisting of the 
portion of bowel which has descended, the outermost consisting of the 
portion into which the descent has occurred, the middle or interme- 
diate length being that which unites the lower extremity of the former 
with the upper extremity of the latter. This last is of course inverted, 
and has its mucous aspect facing outwards and in contact with that of 
the outermost layer. In the descent of the inner two lengths of bowel 
the mesentery belonging to them is necessarily dragged down with 
them into the pouch which they form, and by the traction which it 
exerts tilts the double tube or invaginated portion of bowel so that the 
lower orifice instead of lying in the axis of the containing bowel faces 
and rests upon some portion of its circumference. The several layers 
generally present more or less transverse corrugation, and this condi- 
tion is always most marked in the middle tube. The immediate 
effects of intussusception are : first, more or less obstruction to the 
passage of the intestinal contents ; and, second, more or less impedi- 
ment to the return of blood from the inner two cylinders of involved 
bowel, to which the stretched and compressed mesentery belongs. 
Nevertheless the obstacle which an intussusception opposes is often in- 
complete, for it is certain that in a good many cases fecal matters, not 
always in small quantities, pass pretty constantly through it. The 
obstruction to the venous circulation very soon renders the mucous and 
muscular coats of the inner two tubes black or nearly so with conges- 
tion and effusion of blood into their substance ; and the serous surface 
assumes a more or less deep slate color. At the same time these parts 
become greatly swollen, and sanguinolent serum or blood escapes from 
the mucous membrane into the interval between the opposed mucous 
surfaces of the outer two tubes, into the central canal, and into the 
bowel below the seat of disease. At a somewhat later period coagula- 
ble lymph is secreted from the opposed serous surfaces of the middle 
and internal layers, and these may consequently become agglutinated 
in their whole length. In most cases an intussusception increases for 
a time more or less rapidly, owing to the active peristaltic movements 
of the several segments engaged. This increase is so effected that that 
portion of the bowel which formed the lowest point of the invaginated 
mass in the first instance continues to form its lowest point to the end 
of the chapter ; in other words, the middle tube of an intussusception 
increases in length at its upper end only, and at the expense of the 
outer tube. The length of bowel engaged in an intussusception varies 
widely. Including in one measurement the inner two tubes only it 



678 



DISEASES OF THE DIGESTIVE ORGANS. 



may be said to ran^e usually from two or three inches up to three or 
four feet. Dr. Peacock records a case in which there were good 
grounds for believing it to have amounted to no less than twelve feet. 

Intussusception may arise at any part of the intestinal canal, but it 
occurs in different parts with different degrees of frequency. Jejunal 
and ileac intussusceptions are met with almost exclusively in adults, 
and form collectively about one-third of the total number of fatal cases. 
These are usually attended with rapid strangulation of the bowel, and 
run a rapid and for the most part rapidly fatal course. Ileo caecal 
invagination occurs largely among young children, including babes a 
few months old. According to Dr. Brinton half the total number of 
these cases are in children under seven years of age. This is the most 
common form of the disease, accounting for more than half the total 
number of deaths. It commences with the descent into the cavity of 
the caecum of the lips of the ileo-csecal orifice, which form henceforth 
the lower extremity of the invagination. As this increases the de- 
scending ileo-csecal orifice drags down with it more and more of the 
ileum to form the central tube, and inverts first the caecum and then a 
gradually increasing quantity of the colon to form the inverted or 
middle layer; and, still descending, finally, in some cases, reaches the 
rectum, or even protrudes from the anus. It is in this form of the 
disease that the greatest length of bowel may be engaged ; in it the 
transverse folding of the several layers of intestine is usually well 
shown, especially in the middle tube, which is often also much convo- 
luted and twisted; and in it complete strangulation and complete 
obstruction to the passage of faeces are comparatively rare. Intussus- 
ception, commencing in the colon, is of somewhat unfrequent occur- 
rence; and still more rare is intussusception of the rectum. The 
rarest form of all, probably, is that which is due to the descent of the 
ileum through the ileo-caecal orifice. 

If the patient survive sufficiently long, various consequences are 
apt to ensue. The peritoneal inflammation, which by its products 
unites the opposed serous surfaces of the inner two layers, may spread 
beyond its primary seat, and cause general peritonitis. Or after these 
layers have become united a further descent of bowel may take place 
into the portion already invaginated. Or the extremity of the in- 
vaginated portion may fret the wall of its containing tube and cause 
therein ulceration or even perforation. But by far the most interesting 
and important event is the sloughing and separation of the included 
layers of bowel. This occurs almost exclusively in those cases in 
which the small intestine is alone engaged, and in which strangulation 
of the contained bowel is most complete. This latter, first deeply con- 
gested, soon becomes gangrenous, and then, after awhile, becoming 
detached either bit by bit, or in mass, gradually works its way down- 
wards, and becomes expelled. This separation generally leaves the 
upper extremity of the outer tube firmly united at the neck of the 
intussusception with the lower extremity of the healthy bowel above. 
But sometimes during the process of separation of the slough this 
adhesion becomes ruptured, and fecal matter gets extravasated into the 
peritoneal cavity. The discharge of the invaginated bowel usually I 



OBSTRUCTION OF THE BOWELS. 



•679 



occurs between the twentieth and thirtieth day ; but it may take place 
as early as the sixth or seventh day, or may be delayed for a year or 
two. The results of separation seem to be favorable in about half the 
total number of cases. In the remainder death not uncommonly re- 
sults from the supervention of stricture. 

Symptoms and Progress. — The occurrence of intussusception is at- 
tended with sudden and more or less severe abdominal pain of a grip- 
ing or twisting character, usually referred to the neighborhood of the 
umbilicus. This generally ceases in a short time, but, after an inter- 
val, recurs temporarily, and then perhaps continues to recur and to remit 
alternately. There is not necessarily any abdominal tenderness, and 
indeed the patient frequently finds relief, as in colic, from pressure on 
the abdominal parietes. Sympathetic vomiting may be an early symp- 
tom, but in the beginning is often absent. Constipation generally fol- 
lows upon the sudden attack of pain. Sometimes, on the other hand, 
there is actual diarrhoea, and generally there is more or less abundant 
discharge of blood, which is furnished by the congested bowel. The 
symptoms which mark the subsequent progress of the case depend 
partly on the situation of the intussusception, partly on the degree of 
strangulation. 

In ileo-csecal invagination strangulation is rare, and the case tends 
to become protracted. In this event the symptoms are apt to be very 
ill-defined; the paroxysms of pain are often slight, and recur at distant 
intervals ; constipation may exist at the beginning only, or may recur 
from time to time, or may never be distinctly present; and there is 
generally more or less vomiting. As the case progresses, however, the 
pain often increases in severity; the* vomiting becomes more or less in- 
cessant, and probably stercoraoeous ; the alvine evacuations either con- 
tinue to pass or become re-established; blood and mucus are discharged 
in variable quantities, and even dysenteric diarrhoea may come on. And 
then, after a longer or shorter period, sometimes two, three, or four 
months, the patient, who has been gradually getting emaciated and 
feeble, dies of simple exhaustion. 

When the small intestine is the seat of disease, strangulation usually 
ensues speedily, and its occurrence adds the symptoms of enteritis to 
those of mere invagination. The case, therefore, speedily assumes a 
very threatening aspect. Febrile symptoms manifest themselves, the 
abdomen becomes tender, incessant vomiting comes on, the bowel be- 
comes occluded, but at the same time blood in some abundance is prob- 
ably discharged per anum. With such symptoms the patient, as in 
simple enteritis or internal strangulation, may speedily succumb; but 
sometimes, at a moment when the disease appears still to be progressing 
unfavorably, the constipated bowel begins to act, offensive stools, mixed 
with blood and mucus, begin to be discharged, vomiting diminishes or 
ceases, febrile phenomena abate, and, after a longer or shorter time of 
dysenteric symptoms, a sequestrum is voided in the form of a dark 
fetid gangrenous mass. 

A further indication of the presence of intussusception' is the dis- 
covery of a tumor. No doubt this cannot always be detected; but it is 
most likely to be found in cases of ileo-colic or colic invagination. 



680 



DISEASES OF THE DIGESTIVE ORGANS. 



That the tumor is due to intussusception may be gathered partly from 
its position, partly from its form, partly from the fact of its gradual 
enlargement and change of position, but above all from its hardening 
and enlarging and then subsiding under the influence of peristaltic 
movements. If the tumor descend into the rectum or protrude exter- 
nally, its nature may of course be readily recognized. The distinctions 
which have been drawn between invaginations of the small intestine and 
those of the large — to wit, that in the former case the symptoms are 
usually more sudden and severe, vomiting earlier and more persistent, 
constipation more complete, discharge of blood per anum more profuse, 
inflammation more intense, and death more rapid — are no doubt true 
of the great majority of cases, but they are not to be absolutely relied 
upon; for it occasionally happens that invaginations of the small intes- 
tine assume a chronic character, and still more frequently that those of 
the large take an acute course and even end in the detachment of the 
invaginated portion. The percentage mortality of intussusception is 
very large. It must be observed, however, that in arriving at this 
opinion we necessarily exclude all those cases in which intussusception 
is found accidentally after death from other forms of disease, and those 
cases which we believe to occur now and then in which intussusceptions 
form during life and disappear again after the temporary production of 
symptoms of more or less severity. The average duration of cases fatal 
from enteritis appears to be about five days. 

Concluding Remarks in Reference to Symptoms. 

Before dismissing the subject of intestinal obstructions it may be con- 
venient to consider some of the more important points upon which our 
discrimination of cases that come before us must depend. 

Pain is a more or less general and prominent symptom in all cases 
of obstruction. It is sometimes due to peritonitis, sometimes to colic, 
sometimes to both of these causes. It varies in intensity in different 
cases, and may be almost entirely absent. Pain of peritonitic quality 
attends those cases of obstruction which are accompanied by enteritis, 
and is apt to subside as tympanites supervenes and the fatal event ap- 
proaches. Colicky pains constitute one of the most characteristic and 
at the same time one of the most distressing symptoms of intestinal ob- 
struction. They come on in paroxysms, and are attended with more 
or less violent peristaltic movements of the bowel above the seat of ob- 
struction, which are often distinctly visible through the abdominal pari- 
etes, and may even from their course and point of apparent cessation 
furnish a clue to the seat of impediment. These pains may be present 
in a marked degree in ail forms of obstruction, but are most severe and 
most constant in the cases of longest duration — in those, therefore, in 
which enteritis is either not present at all or comes on late. 

Vomiting is rarely, if ever, entirely absent. At first it is merely 
sympathetic. But after awhile it is due to mechanical causes. The 
bowels above the seat of the obstruction become distended by their 
contents, which are partly the ingesta, partly the secretions of the mu- 
cous surface. These, by the combined effects of simple overflow, of 



OBSTRUCTION OF THE BOWELS. 



681 



peristaltic action, and of pressure from without, regurgitate into the 
stomach, and then become voided, constituting what is called stercora- 
ceous vomit. This may be peasoup-like and fetid from decomposition, 
but is never derived from the large intestine and is never truly fecal. 
Vomiting is generally an early symptom in all cases of intestinal ob- 
struction, and in those of acute progress may continue to the end with- 
out cessation. Yet even in some of these it intermits, and may be 
absent for a comparatively long period. In more chronic cases its 
occurrence is extremely variable ; but even here it generally becomes 
more or less constant and stercoraceous towards the close of life. 
Vomiting is an earlier, more constant, and more severe symptom, in 
proportion to the nearness of the seat of obstruction to the stomach. 
In obstruction of the large intestine it is usually long delayed, and may 
never be a prominent symptom. 

Constipation is of course one of the most characteristic phenomena 
of obstruction ; yet fecal matters will often pass with little difficulty 
through even a tight stricture, especially of the small intestine. Nor 
must it be forgotten that generally at the time at which complete ob- 
struction is established, the bowel below contains larger or smaller 
quantities of faeces, which may be removed naturally or by injections. 
Scybala are sometimes found post mortem in the large intestine below 
a complete obstruction of many weeks' standing. Nevertheless, in- 
superable constipation coming on suddenly is a striking feature of 
internal strangulation and of the lodgment of gallstones; insuperable 
constipation coming on gradually or with premonitory stages, of stric- 
ture and compression. In intussusception also there is generally sud- 
den constipation of various duration, but the invaginated mass, especi- 
ally when the large intestine is involved, is rarely quite impervious, 
so that before long, at all events in chronic cases, the transmission of 
fecal matters is resumed. In intussusception, moreover, blood is apt 
to be passed at an early period by stool ; and is generally passed in 
abundance when the small intestine is the part affected. 

Tumor and Shape of Belly. — The belly usually becomes before long 
more or less tense and tympanitic in consequence of the accumulation 
of gas in the parts above the seat of obstruction ; and the form of the 
stomach or of certain convolutions of the bowels may sometimes be 
distinctly mapped out. Careful attention to the form of the belly, to 
the visible movements of the organs beneath, and to the sounds elicited 
by percussion will often aid us in determining the seat of disease. Still 
too much reliance must not be placed upon these phenomena, for cer- 
tain lengths of bowel become in some cases so enormously distended 
that they not only conceal all the other viscera, but a coil of small 
intestine may equal in diameter a distended colon, and either of them 
may simulate the stomach. The detection of a lump is an indication 
of capital importance. It may be due to the presence of a gallstone 
or some other concreted mass lodged in the bowel ; it may (in cases of 
stricture) be a mass of malignant disease ; it may be the evidence of 
intussusception. 

The condition of the urine is a matter of interest. In some cases of 
obstruction there is almost total suppression ; in some there is an 



682 



DISEASES OF THE DIGESTIVE ORGANS. 



abundant limpid discharge. Dr. Barlow, who first observed this dif- 
ference, attributed scantiness of urine to the obstruction being high up 
in the bowel, and to the consequently little available surface left for 
absorption ; plentifulness of urine to the opposite conditions. Dr. 
Brin ton, accepting Dr. Barlow's facts, referred the deficiency of urine 
to the abundant vomiting which attends the one class of cases, and the 
copious secretion of that fluid to the comparative absence of vomiting 
which is usual in the other class. Mr. W. Sedgwick, however, argues 
that the diminution or suppression of the urinary secretion is related 
to the suddenness and intensity of the symptoms, and is due to the 
influence of the sympathetic system. On the whole, there is reason to 
believe that the diminished secretion, which is often only temporary, 
characterizes mainly those cases in which the symptoms are sudden and 
acute; and almost necessarily, therefore, in larger proportion, cases in- 
volving the small intestine than cases involving the large. 

Duration of Life. — Complete obstruction occurring in the rectum or 
colon may not prove fatal for several weeks or even several months. 
Death as a rule supervenes earlier in proportion as the impediment is 
situated near the stomach. When, however, enteritis is associated with 
obstruction, then, wherever the obstruction may be, the progress of 
the case is always very rapid, and, dating from the commencement of 
enteritic symptoms, rarely occupies more than a week, often only three 
or four days. 

Statistics. — According to Dr. Brin ton's figures, based on 500 deaths 
from obstruction, it appears that in every 100 cases 43 are due to in- 
tussusception, 17 to stricture, 4.8 to impaction of gallstones, 27.2 to 
internal strangulation (including, however, all those cases which have 
been ascribed above to compression or traction), and 8 to torsion or 
twisting — a condition which we are disposed to regard as a mere con- 
sequence of enteritis. 

Treatment. 

1. The treatment of constipation turns, in different cases, upon very 
different considerations. A temporary attack may be put right by the 
use of a simple purge — a dose of castor-oil, a black draft, a colocynth 
pill, or a simple enema. In young babies the mere introduction of 
the nozzle of the enema tube, or the insertion into the anus of the 
point of a piece of soft paper rolled into the form of a pencil, is often 
amply efficacious. When constipation is of a more permanent char- 
acter it may often be overcome by the mere persistent repetition of 
daily efforts at some particular time (preferably after breakfast) to 
evacuate the rectum ; or by the habitual use of particular kinds of 
food, such as brown or bran bread, a large proportion of fresh vege- 
tables or of fruit, or of dried fruit, such as plums and figs ; or, again, 
by the daily use of small doses of mild laxatives, such as a few stewed 
prunes, a teaspoonful of confection of senna or of castor-oil, taken in 
the morning, on an empty stomach ; or by the similar employment of 
a combination recommended by Trousseau of one-sixth or one-seventh 
of a grain of podophyllin combined with an equal quantity of extract 
of belladonna. In some of these cases a course of iron or strychnia, 



OBSTRUCTION OF THE BOWELS. 



683 



or of belladonna or atropia in small closes, either alone or combined 
with mild aloetic or other purgatives which act especially on the lower 
bowel, is serviceable, as also is the occasional employment of simple or 
purgative enemata. Galvanism applied to the surface of the abdomen, 
or to that and to the anns, is occasionally efficacious. In some cases 
much more active purgation is needed • and in some it becomes abso- 
lutely necessary to dislodge the hard fecal accumulation by the finger, 
spoon, or some such instrument ; or by the use of repeated enemata ; 
or, better still, by directing a forcible stream of warm water, conducted 
from a height, by means of a tube, into the rectum, and allowing it to 
play upon the fecal mass for half an hour or so at a time, and thus to 
cause its disintegration, and either effect or facilitate its removal. 

2. The treatment of cases of obstructed bowel must be regulated 
partly in accordance with what w T e know or suspect of the nature of 
the cause of obstruction, partly in accordance with the character of the 
symptoms present. It may be laid down as a general rule, from which 
it is highly unsafe to depart, that, whenever the symptoms of obstruc- 
tion are associated with those of enteritis — whenever, in fact, there is 
besides obstruction obvious inflammation — the treatment to be adopted 
is that already recommended for cases of enteritis, viz., the local ab- 
straction of blood, and the application of fomentations, the use of 
opium in sufficiently large quantities, the avoidance of purgatives, the 
administration of food in small portions and in the liquid form, and 
all those subsidiary measures which are elsewhere considered in suffi- 
cient detail. This is the form of treatment that is especially applicable 
to cases of internal strangulation, of impaction of foreign bodies, and 
of jejunal or ileac intussusception. 

In those cases, however, in which the symptoms of obstruction come 
on vaguely and without evidence of association with inflammatory 
mischief, it is generally advisable to commence the treatment with the 
administration, either by the mouth or rectum, of moderately powerful 
purgatives, and to persist in this treatment until, by their failure to 
act, and by their causing vomiting, and painful but fruitless peristaltic 
movements, their inefficacy is distinctly shown. It sometimes happens 
that, after drastic purgatives have failed, a large dose of some simple 
laxative, such as castor oil, acts with singular efficacy. In aid of this 
treatment, hot baths, fomentations, or ice or electricity to the surface 
of the belly, and voluminous enemata of gruel or of water may sev- 
erally be employed. If these measures are without avail, it is gen- 
erally advisable to give the bowels rest, and to relieve pain by the re- 
peated use of adequate doses of opium or of belladonna; the persistence 
in which treatment will, by relieving spasm or otherwise promoting 
the return of some length of bowel to a comparatively healthy condi- 
tion, not unfrequently result, after a shorter or longer time, in an ef- 
fectual and sufficient evacuation. If this treatment fail in its turn, it 
may be necessary again to solicit the action of the bowels by the em- 
ployment of purgative medicines, enemata, and the like. Such is the 
routine that must generally be followed in cases of simple obstruction, 
in which the cause of obstruction is obscure ; and in many cases, also, 
even when the cause is distinctly ascertained. 



684: 



DISEASES OF THE DIGESTIVE ORGANS. 



When, however, the obstruction depends on the presence of a stric-. 
ture in the rectum or sigmoid flexure, the persistent use of powerful 
purgatives is scarcely judicious ; copious and frequently repeated ene- 
mata are then of especial value. If the stricture be within reach it 
may admit of dilatation by the bougie. Again, when the obstruction 
is due to an ileo-csecal or to a colic intussusception, powerful purgation 
is likely to do more harm than good ; large enemata, however, are 
occasionally efficacious in causing the reduction of the intussuscepted 
bowel. But the most powerful, and apparently the most efficacious, 
form of enema for this purpose appears to be the inflation of the large 
intestine with air. Lastly, when, in cases of obstruction, the bowel 
is working with visible violence and pain ; or we have reason to 
believe that (as in the course of those cases in which the invaginated 
portion of bowel is discharged per anum, and in all cases where there 
is, and has been for some time, much tympanites) the bowel is enfeebled 
and in danger of rupture, purgatives must be religiously avoided. 

In the course of many cases of obstruction, the question of relieving 
the patient by the performance of a surgical operation must necessarily 
arise. The time at which an operation should be performed, and the 
nature of the operation to be performed, are of course matters of grave 
importance. It may be accepted as a general rule that when once the 
desirability of this procedure has been recognized, the earlier recourse 
is had to it the better. Exploratory operations with the object of dis- 
covering the nature of the impediment, and then, if possible, of reliev- 
ing it, are very rarely indeed successful. There are, however, some 
circumstances under which operations are not only justifiable, but im- 
peratively demanded. No patient who has either a rupture (even if 
there be no evidence of strangulation in it) or a hernial sac, or any 
trace or hint of any affection of the sort, should be permitted to die 
with symptoms of obstruction without having the chance afforded him 
which an exploratory operation at the suspected site affords ; nor ought 
we, with the object of unfolding the involved bowel, to hesitate to per- 
form gastrotomy in cases of ileo-csecal intussusception which have re- 
sisted other modes of treatment. Other operations which are often 
serviceable in prolonging life, and are sometimes curative, consist in 
opening the bowel and forming an artificial anus in some convenient 
spot above the seat of obstruction. Such operations are especially 
applicable when the large intestine is the seat of disease. If the ob- 
struction be in the rectum or sigmoid flexure, the opening should be 
made in the left loin into the descending colon; if above these portions 
of the bowel, then in the right loin and into either the caecum or the 
ascending colon. If the obstruction be in the caecum itself, or in the 
small intestine, Littre's operation is alone available. This consists in 
laying open the peritoneal cavity, and then opening the bowel (having 
first brought the part to be divided to the surface) above the seat of 
stricture. The lips of the wound in the intestine must be attached by 
sutures to those of the incision in the abdominal walls. The enormous 
gaseous distension of the bowel which often takes place in obstruction 
is a cause of great discomfort, and even adds to the patient's risks. It 
may be much relieved by puncturing the distended gut through the 



ASCITES. 



685 



abdominal parietes with either a grooved needle or a very fine trocar 
and canula. The operation is attended with little or no danger. 

[7. Volvulus. 

In this form of obstruction which is of sufficiently frequent occurrence 
! to merit at least a passing notice, a portion of the bowel becomes twisted 
1 or folded upon itself so that its calibre is entirely occluded. In many 
| cases this takes place as a complication of stricture, and as a matter of 
course greatly increases the original obstruction ; but in the cases here 
referred to, there has been no antecedent disease of the bowels, certainly 
none of a grave character. Any part of the intestine may be involved 
in this accident, but the caecum and sigmoid flexure appear to be its 
most frequent seat. Its causes are not definitely known. In some of 
the reported cases it occurred in the course of an attack of diarrhoea, 
and in a case which came under Sir A. Cooper's observation, it fol- 
lowed a blow upon the abdomen. 

The symptoms depend in great measure upon the part of the bowel 
affected, and do not differ materially from those presented by intussus- 
ception. They are in fact so little characteristic that it is not always 
possible during life to distinguish this from other forms of obstruction. 
Since, however, the mesentery is also involved in the twisting, the 
early supervention of peritonitis which speedily assumes an intense 
form, may sometimes indicate the true nature of the accident. 

The jyi'ognosis is always grave, and little can be done in the way of 
treatment, except to assuage the patient's sufferings. The same reme- 
dies may be employed as were recommended in the article on intussus- 
ception. It is questionable, however, whether a surgical operation will 
ever be of much service, since peritonitis is so frequent and early a 
complication of this form of obstruction. In a case reported by Dr. 
Hilton Fagge, when the volvulus was gently untwisted after death, 
it did not remain so, but sprang back at once into its abnormal posi- 
tion.] 



ASCITES. {Abdominal Dropsy.) 

Causation and Morbid Anatomy. — The above terms are applied to 
the accumulation of serum within the peritoneal cavity. Ascites is an 
accompaniment or sequela of many different forms of disease; but 
depends immediately on some condition which modifies the action of 
the capillary vessels or of the lymphatics of the peritoneal membrane. 
This condition may be, first, some morbid process going on in the peri- 
toneal tissue ; second, some impediment to the flow of blood through 
the portal system of vessels ; or, third, some disease influencing the 
systemic circulation generally. 

1. A greater or less effusion of serum attends ordinary cases of acute 
peritonitis. Such accumulations, however, are rarely abundant, and 



686 



DISEASES OF THE DIGESTIVE ORGANS. 



generally soon disappear. Chronic peritonitis, on the other hand, is 
a common cause of persistent and progressive ascites, and especially 
perhaps those forms of chronic peritonitis which occur in women in 
connection with inflammatory conditions of the pelvic organs and the 
formation of ovarian cysts. In some of these latter cases the ascites is 
due to the rupture of cysts and the discharge of their contents into the 
peritoneal cavity. Tuberculosis and malignant disease of the perito- 
neum are other frequent causes of ascites. 

2. Impediment to the flow of blood along the portal veins, and con- 
sequent ascites, may be due to direct compression of the portal trunk 
by cancerous, aneurismal, or hydatid tumors arising external to the 
liver, or by tumors of various kinds originating within its substance, 
and especially by cancerous and fibroid growths occupying the lesser 
omentum and extending thence into the liver along the capsule of 
Glisson. Most commonly, how r ever, they are caused by general hepatic 
diseases involving the hepatic capillaries and the minute veins which 
open into and emerge from them. Of these cirrhosis is the most fre- 
quent and important. But the simple induration and congestion 
which constitute the "nutmeg liver" may have the same effect, as 
also possibly may lardaceous degeneration. The compression of the 
liver by a fibroid capsule of inflammatory origin may act in the same 
way as cirrhosis. 

3. Among the diseases by which dropsical effusion into the belly, 
as a part of general dropsy, may be caused, are heart disease, chronic 
affections of the lungs, and certain forms of renal disease ; to which 
may probably be added various cachexia? and simple anaemia. In 
many of these cases the ascitic accumulation is proportionate only to 
the dropsy in other parts. In some cases, however, it becomes excessive, 
while the dropsy elsewhere undergoes but little increase. When this 
is the case there is generally some local complication (coming under 
the first or second group of causes which have been considered) to 
which this disproportion is attributable. 

The amount of fluid present in ascites may vary between a few pints 
and four or five gallons. Its quality also may vary. It is usually 
slightly viscid, transparent, of a yellowish or greenish tinge, alkaline, 
and containing both albumen and fibrinogen, and often fibrinous clots. 
It is sometimes very viscid (especially in cases of ovarian tumors or 
colloid cancer), sometimes opaline from the presence of inflammatory 
or other products ; or may contain blood in a more or less altered form. 

Symjjtoms and Progress. — The accumulation of fluid in the abdomi- 
nal cavity causes its gradual distension, and sooner or later obstructs 
the intra-abdominal veins, especially those connected with the lower | 
extremities, impedes the movements of the diaphragm, and interferes 
more or less injuriously with the healthy action of the abdominal 
viscera. It modifies also the patient's gait, making him walk like a 
pregnant woman, with his legs wide apart and his head and shoulders 
thrown back. The ascitic abdomen is large, uniformly rounded, with 
a tendency to spread or bulge in the flanks as the patient lies on his 
back, tense, and more or less smooth and shining, and often presents 
distended superficial veins and that linear atrophy of the skin so com- 



ASCITES. 



687 



mon in pregnancy. The stomach and intestines tend of course to float 
on the surface of the fluid ; and hence generally the highest part of the 
abdomen is resonant, the more dependent parts dull — the line of de- 
marcation between them being for the most part well defined and 
horizontal, but varying with the varying positions which the patient 
assumes. The liver, which is of higher specific gravity than dropsical 
fluid, often retreats distinctly from the anterior surface of the abdomen 
and from the diaphragm, a stratum of fluid with sometimes a loop of 
bowel occupying the interval. The presence of fluid is further indi- 
cated by the peculiar thrill which is experienced by the hand laid flat 
on the abdomen, when a ripple or wave is produced in the ascitic fluid 
by a slight tap or fillip applied to some other part of the abdomi- 
nal surface. 

These signs are not always all present, or at least easy to recognize; 
and not unfrequently tumors and other forms of disease simulate or 
mask abdominal dropsy. The fluid may be so small in amount that it 
occupies the pelvis only ; it may then, however, often be detected by 
making the patient rest on his knees and elbows so as to allow it to 
gravitate to the neighborhood of the umbilicus. It may be so abun- 
dant that the stomach and bowels fail to reach the surface, in which 
case the dulness may in all positions of the body continue general, ex- 
cepting, perhaps, in the course of the ascending and descending colon ; 
but here fluctuation will almost certainly be well marked. Or there 
may be adhesions limiting the distribution and mobility of the ascitic 
fluid; or there may be adventitious growths in the abdominal cavity; 
or the parietes may be fat or cedematous. All such conditions tend 
more or less to interfere with the formation of an accurate diagnosis. 

In most cases ascites causes pretty uniform distension ; but in some, 
where pouches exist, or the parietes are specially thin and yielding, 
this uniformity becomes interfered with. Thus hernial sacs, whether 
at the umbilicus or at the groin, get distended with fluid ; and in 
females the recto- vaginal pouch sometimes becomes so much dilated 
that it protrudes through the vulva in the form of a tumor, carrying 
with it as a covering the posterior wall of the vagina. 

GEdema of the lower extremities and genitals is a common and early 
accompaniment of ascites. It sometimes occurs so early that the patient 
observes it before his attention is particularly directed to the condition 
of his belly. It is doubtless due (when thus limited and unconnected 
with cardiac or other equivalent disease) to the pressure exerted by the 
ascitic fluid on the iliac veins, and is generally fairly equal in the two 
limbs. Shortness of breath is an early symptom. It depends on the 
mechanical impediment which the accumulated fluid opposes to the 
descent of the diaphragm, and increases, therefore, with the increase of 
the accumulation. It is sometimes so slight that the patient only ob- 
serves it when he exerts himself ; sometimes it is exceedingly distress- 
ing; and it is usually increased when he lies down. The lower parts 
of the lungs are apt to become empty of air and collapsed. More or 
less abdominal discomfort or pain, mainly in the lumbar regions and 
about the umbilicus, generally arises in the course of the affection. 
This is often of an aching, flatulent, or colicky character, and is proba- 



638 



DISEASES OF THE DIGESTIVE ORGANS. 



bly in some degree due to the pressure which the fluid exerts on the 
hollow viscera and other organs. Sometimes it is peritonize, and 
indeed the supervention of acute or subacute peritonitis is not rare in 
the later stages of ascites. Although early in the affection there may 
be no visible morbid condition of tongue, and neither thirst nor loss of 
appetite, the tongue and the digestive functions become after awhile 
variously and more or less seriously affected. Diarrhoea especially is a 
by no means uncommon complication ; and is due sometimes to the 
same impediment to the portal circulation as causes the ascites, some- 
times to slight dysenteric disease. There is also generally some dry- 
ness of skin and diminution of the urinary secretion. Other symptoms 
more or less grave are usually presented by ascitic patients ; but they 
are for the most part the symptoms of the morbid conditions on which 
the ascites itself depends, and are sufficiently considered elsewhere. 

Treatment. — The treatment of ascites merges, in a large proportion 
of cases, in the treatment of the diseases out of which it arises. Still 
there are many cases in which sooner or later special treatment directed 
against the ascites itself is demanded. To promote the absorption and 
removal of the dropsical accumulation there are good theoretical reasons 
for the employment of those remedial measures which increase the dis- 
charges from the skin, the kidneys, and the bowels. For diaphoretic 
purposes we must not forget the value of the hot bath, the vapor bath, 
and the Turkish bath. Among diuretics must be especially signalized 
iodide of potassium, copaiba, and the combination of crude mercury, 
fresh squills, and digitalis. Of purgatives, those which promote watery 
evacuations are obviously the most likely to prove efficacious. We 
are bound, however, to state that, while acquiescing in the importance 
of restoring, so far as may be, or of maintaining the healthy action of 
the skin and kidneys, and of acting freely on the bowels, we have 
never been satisfied of the efficacy of such measures in causing the 
removal of the dropsical fluid. And indeed, as regards purgatives, 
we have frequently had to discard them, because, while not distinctly 
benefiting the dropsy, they were in other ways obviously affecting the 
patient's health injuriously. Further, the diarrhoea which comes on 
spontaneously in the course of ascites is not only not curative, but is 
difficult to arrest, and very often of bad augury. In a large number 
of cases, no doubt, all medicines are alike inefficacious, but there are 
many in which the general improvement of the patient's health, no 
matter how brought about, is followed by the subsidence of the dropsy. 
Tonics, of which quinine, iron, and cod-liver oil are probably the best, 
are especially valuable in this respect. It is certain that they are often 
well borne by ascitic patients, and that, even when not well borne at 
first, a little judiciousness in their selection and mode of exhibition will 
render them tolerable ; and it is certain that, under their use, patients 
not only improve in general health, but lose in part or wholly their 
dropsical accumulations, and that occasionally their recovery is perma- 
nent, and permanent even after the performance of paracentesis. Local 
applications to the abdomen are only needed to relieve pain or uneasi- 
ness, but when the abdominal distension becomes so great as to cause 
the patient serious suffering or distress, the fluid must be removed by 



HiEMATEMESIS AND MEL^NA. 



689 



paracentesis. This operation is usually delayed as long as possible, 
and on the whole no doubt properly so. There is nevertheless reason 
to believe that the beneficial effect of remedies is sometimes exerted 
much more markedly immediately after paracentesis than while the 
abdomen is pretty full of fluid. Paracentesis, though usually a harm- 
less operation, is sometimes followed by peritonitis. It is rarely of even 
temporary benefit in the ascites which accompanies malignant disease. 



HEMORRHAGE. HiEMATEMESIS. HELENA. 

Definition. — When blood is vomited, the affection is termed hcema- 
temesis; when blood is passed by stool, and is of a black color, as it 
usually then is, the term melcena is applied. 

Causation. — Gastrointestinal haemorrhage may be due to the influ- 
ence of diseases in which the quality of the blood is altered, such as 
the infectious and malarious fevers, purpura, and scurvy; to mechani- 
cal impediments to the passage of blood through the portal system, or 
any of its tributary branches ; and to congestion, inflammation, breach 
of surface, and morbid growths involving, any part of the mucous mem- 
brane. It occasionally also occurs vicariously of menstruation. 

Profuse haemorrhages arise mainly from chronic ulcers of the stom- 
ach or duodenum, or from general hyperaemia of the gastro-intestinal 
mucous membrane, coming on in the course of portal congestion, due 
either to cirrhosis of the liver or to obstruction of the portal trunk. 
But besides these causes must be especially named carcinomatous and 
villous growths of the stomach and bowels, and the rupture of aneu- 
risms. It must not be forgotten, however, that haemorrhage, which 
must be regarded clinically as haematemesis, often comes from the oesoph- 
agus, and may then be due to malignant disease, causing perforation 
of the oesophageal, intercostal, or other neighboring vessels, or to the 
rupture of aortic and other aneurisms, or of dilated veins; and further, 
that blood vomited from the stomach may have been previously swal- 
lowed, as sometimes happens accidentally in epistaxis, or designedly, 
and for the purpose of deception. Copious haemorrhage sometimes 
takes place from typhoid or dysenteric ulcers. 

Symptoms and Progress. — It may be taken as a rule, to which there 
are few exceptions, that blood discharged from any part of the alimen- 
tary canal below the duodenum is voided solely by the anus with the 
faeces. And although haemorrhage from the stomach, duodenum, or 
oesophagus is no doubt, in a large number of cases, attended with more 
or less obvious haematemesis, it must not be forgotten that in almost 
all cases a larger or smaller quantity of the blood which finds its way 
into the stomach is passed onwards into the bowels, and that in some 
the whole bulk of it is thus transmitted. These, it need scarcely be 
said, are facts of great practical importance, inasmuch as abundant 
gastro-intestinal haemorrhage may take place, and may continue for 
some length of time, causing progressive and extreme anaemia, without 

44 



690 



DISEASES OF THE DIGESTIVE ORGANS. 



revealing its presence to the patient himself, or to the medical man, 
who fails to investigate the condition of the stools. 

The recognition of blood in the vomit or feces is not generally diffi- 
cult. If it escape in small quantity, either into the stomach or intes- 
tine, it becomes mingled with the other contents of these viscera, which 
acquire a grumous, coffee-ground, sooty, or pitchy character, and how- 
ever abundant it may be, the longer its detention in the alimentary 
canal, or the longer the journey which it has to perforin along it, the 
darker and blacker, as a rule, it appears at the time of its discharge. 
Under other circumstances it may be voided almost pure, sometimes 
fluid, sometimes coagulated, and though generally of a dark hue, in 
some instances of a vivid arterial tint. If there be a doubt as to the 
presence of blood, the microscope will probably clear it up. When, 
however, the blood-corpuscles are wholly destroyed, and blood-pigment 
alone is left, some difficulty of identification may be experienced, and 
it may be necessary to have recourse to chemical investigation or to the 
spectroscope. It is, of course, important not to confound the discolora- 
tion of the vomit and faeces, due to articles of diet (port wine and the 
like), to drugs (iron, bismuth, and mercury), or to bile, with that de- 
pendent on the presence of blood. 

Small haemorrhages are in themselves of little moment; their fre- 
quent repetition, however, necessarily tends to induce more or less 
marked anaemia, and the various symptoms which attend anaemia. 
Copious haemorrhages, on the other hand, are alarming in their imme- 
diate symptoms, and of extreme danger to life. 

The occurrence of copious haemorrhage into the gastro-intestinal 
canal is usually attended with sudden fain tn ess ; sometimes indeed the 
patient falls down insensible and becomes convulsed. The phenomena 
are those of the rapid abstraction of a large quantity of blood, but are 
also not unlike such as may attend the sudden effusion of blood into 
the substance of the brain, or the commencement of an epileptic seizure. 
From this attack of faintness, the patient usually soon recovers some- 
what ; and then, if the haemorrhage have taken place into the stomach, 
he usually ere long vomits a more or less considerable quantity of blood, 
sometimes as much as a quart or two at one time or within a short 
period, and later on passes a greater or less bulk of pitchy matter by 
stool. In some cases, as has been pointed out, no vomiting of blood 
takes place, but melaena alone supervenes. The recognition of the in- 
itial symptoms as due to gastro-intestinal haemorrhage depends, indeed, 
on the supervention of haematemesis, or melaena, or both. 

The further progress of such cases depends largely upon their cause. 
In some instances the patient dies from sudden faintness, or falls into 
a condition of collapse from which he never recovers. In some he is 
suffocated by the entrance of blood into the air-passages. In some the 
haemorrhage is repeated over and over again, the patient becomes ex- 
cessively anaemic, the usual symptoms clue to recurrent losses of blood 
ensue, and at length probably death occurs. In some cases he makes 
a good recovery, and possibly never has a return of his malady. 

Treatment — An accurate diagnosis of the cause and seat of bleeding 
in haematemesis and melaena is very important in reference to treatment, 



DYSPEPSIA. 



691 



and must rest partly on close observation of the phenomena which the 
case presents, partly on a careful inquiry into its history, but is in many 
cases for a time at least absolutely impossible. There are certain meas- 
ures, however, which under any circumstances should be taken. The 
])atient should be placed and kept in the supine position, forbidden to 
use any muscular exertion, and guarded from all causes of mental ex- 
citement; the stomach and bowels should be kept as far as possible at 
rest, and hence generally purgatives and emetics, solid food and stimu- 
lants should be eschewed, and fluid food should be given in small quan- 
tities ; and the force of the circulation should be restrained, a result 
which is in some degree attainable by perfect quiescence of mind and 
body, by keeping the outer surface only moderately warm, and by the 
use of certain medicines, of which digitalis and lead are among the 
most valuable. Simple styptics are not generally of much use in re- 
straining haemorrhage, unless they can be directly and well applied to 
the bleeding surface; and hence their value is not generally very great 
in restraining gastro-intestinal haemorrhage. It can, however, at least 
do no harm to employ them. Among such remedies may be named 
perchloride of iron, sulphuric acid, tannic acid, and turpentine. Ice 
and ice-cold drinks are serviceable, as well for their astringent as their 
sedative influence. Ice may also be applied with benefit to the surface 
of the chest or abdomen. When we have reason to believe that the 
haemorrhage is due to an overloaded state of the portal system, it is 
commonly regarded as injudicious, if not useless, to attempt to restrain 
it. And indeed it is often recommended that the bowels should then 
be acted on by repeated and tolerably strong purgatives, with the ob- 
ject of relieving the distended vessels. It must be remarked, however, 
that this variety of gastro-intestinal haemorrhage is probably the most 
frequently fatal of all varieties; and that death, when it occurs, is gen- 
erally due simply to the loss of blood. It seems scarcely reasonable, 
therefore, in such cases to promote, by stimulating the bowels, a kind 
of relief which is so dangerous to the patient's life, and which, even 
without such stimulation, is only too often apt to be fatal. The blood, 
indeed, which comes away is probably derived mainly, if not entirely, 
not from the overloaded portal system, but from the systemic arteries 
which feed that system, and directly from the congested capillaries dis- 
tributed to the mucous surface. We should therefore recommend the 
employment not only of cold and of astringents to the alimentary tract, 
but of all those measures which have been noticed as tending to soothe 
and regulate the circulation. The further treatment of gastro-intestinal 
haemorrhage must depend on the nature of the primary disease from 
which the patient is suffering, and of the special features w T hich his case 
from time to time exhibits. 



DYSPEPSIA. {Indigestion.) 

No account of the diseases of the alimentary canal and its appen- 
dages would be deemed complete unless it comprises some separate con- 
sideration of dyspepsia or indigestion, that most common and fashiona- 



692 



DISEASES OF THE DIGESTIVE ORGANS. 



ble of all complaints. It is difficult, however, to know how to deal 
with it ; for, on the one hand, it includes within itself all those func- 
tional derangements of the stomach which attend and help to charac- 
terize the various diseases of that viscus, and many of those of the rest 
of the alimentary canal, and of the glandular organs opening upon its 
mucous surface, together with such derangements as are connected with 
general morbid states of the system, and such as depend upon the 
quality, quantity, and condition of the alimentary matters taken into 
the stomach ; while, on the other hand, it is often regarded as the col- 
lective name for groups of morbid symptoms, referable to the stomach, 
which are independent of any discoverable local or constitutional dis- 
ease. In the former point of view, dyspepsia ranges throughout the 
whole domain of clinical pathology; in the latter, the advance of patho- 
logical knowledge tends day by clay to restrict more and more the limits 
of its applicability. To discuss dyspepsia in the former sense would 
be utterly beyond the scope and purport of the present work ; to con- 
sider it strictly in the latter sense would be at once difficult and un- 
satisfactory. The most convenient course will probably be to consider 
briefly the causes of dyspeptic symptoms ; the several local phenomena 
which constitue dyspepsia ; the sympathetic and other consequences to 
which dyspepsia may give rise ; and, lastly, its medical treatment. 

Causation. — The causes of dyspepsia may be conveniently divided 
into three groups : namely, those connected with the ingestion of food ; 
those connected with morbid conditions of the stomach; and those con- 
nected with derangements or diseases of other organs or of the general 
system. In the first group are comprised many pregnant causes of in- 
digestion — causes, some of them, none the less important because they 
involve the habitual and conscious transgression of obvious sanitary 
laws. Among them may be included the following : Imperfect masti- 
cation, or the bolting of food, arising usually from undue haste in eat- 
ing, or from defect or absence of teeth, or from soreness or paralytic con- 
ditions of the mouth : Active bodily or mental exertion immediately before 
or after a meal : Overeating, whether this consist in a single surfeit, or 
in that habitual indulgence to excess of which so many of us are guilty, 
and which is specially injurious if it go along with sluggish sedentary 
habits: Insufficiency of food: Improper arrangement of meeds, such, for 
example, as the taking of one meal only during the twenty-four hours, 
or the crowding of all one's meals within a period of eight or ten hours, 
leaving the remainder of the four-and-twenty without any, or the prac- 
tice (included to some extent under the last head) of interpolating meals 
between the more important meals, and thus refilling the stomach ere 
it has had time to rid itself of its previous load: Injudicious admixture 
of foods — of the frequently injurious influence of the admixture of many 
different kinds of even wholesome articles of diet there can be no doubt; 
it is difficult however, to lay down any exact rule in regard to this 
matter, for, within limits of moderation, variety is conducive to health, 
and the too strict limitation to one or two kinds of food not unfrequently 
proves as detrimental as excessive heterogeneous indulgence: The use 
of indigestible or unwholesome aliments — this might serve as the text for 
a very wide discussion ; it is sufficient, however, to point out here that, 



DYSPEPSIA. 



693 



in addition to substances which may be regarded as generally more or 
less injurious, there are many which become injurious only from the 
circumstances or conditions under which they are taken, or from tem- 
porary or permanent peculiarities in the constitution of the sufferer, or 
in the condition of his digestive organs; thus sometimes mutton, or 
pork, or veal, or game, or shellfish disagrees, sometimes pastry, or milk, 
or eggs, sometimes different, forms of vegetables or of fruit, sometimes 
tea or coffee. To these causes may be added the abuse of alcoholic 
stimulants, or of tobacco, and the excessive indulgence in condiments, 
and perhaps also the habitual abstention from certain kinds of food 
which are essential to the due maintenance of the integrity of the 
organism. The second group of causes, that which embraces the morbid 
conditions of the stomach itself, is also necessarily a very extensive 
group. It includes, moreover, all those morbid conditions which have 
been already described, and the presence of any one of which removes 
the case from among the dyspepsia? in the restricted sense of that term. 
The following is a list of the more obvious of the conditions here ad- 
verted to : Catarrhal inflammation and congestion of the mucous mem- 
brane — these are amongst the most persistent causes of dyspeptic symp- 
toms, and are often the immediate cause of such symptoms attending 
the various alimentary abnormalities just enumerated: Gastric ulcer: 
Carcinomatous and other morbid growths: Abnormal dilatation of the 
stomach, whether this be of primary origin, depending upon inherent 
feebleness of the walls, or habitual overloading of the organ, or whether 
it be secondary to pyloric or other obstructions to the onward passage 
of alimentary matters : Diminution in size, whether arising from the 
gradual contraction of infiltrating growths in the gastric walls, or from 
long-continued abstinence, or from spasmodic action of the muscular 
walls of the stomach referable to irritability of the mucous membrane 
or other sources of reflex action : Degenerative changes of the mucous 
membrane, such as may result from chronic catarrhal inflammation, or 
from the abuse of alcohol, or may arise in the course of chronic wasting 
diseases: And, lastly, functional derangements, including irritability, 
and excess, diminution, or derangement of the gastric secretions. The 
third group of causes again is one of very great extent. It includes, in 
the first place, all those conditions of the alimentary canal — constipa- 
tion and the like — which react on the functions of the stomach; all 
those morbid states of surrounding organs which lead to pressure on 
the stomach and interference with the due performance of its duties; 
all those lesions of the portal system, of the lungs, heart, and kidneys, 
which, by impeding the circulation, induce congestion or other abnormal 
conditions of the stomach ; all those disturbances of the nervous system 
(among which may be included powerful mental impressions or emo- 
tions, and the reflex phenomena of early pregnancy), which influence 
the actions of the stomach; and, lastly, all those general diseases — 
ansemia, pulmonary phthisis, fevers, and innumerable others — of which 
difficult, or painful, or faulty digestion forms an appreciable, if not a 
prominent, symptomatic feature. 

Symptoms Referable to the Stomach. — The symptoms which attend 
and indicate dyspepsia are to a large extent those which also accompany 



694 



DISEASES OF THE DIGESTIVE ORGANS. 



in a greater or less degree the various organic lesions of the stomach. 
They comprise derangements of appetite, derangements of sensation, 
flatulence and eructation, and nausea and vomiting. 

The appetite in dyspeptic patients is very variable. In some cases 
it remains but little affected, or there is simply a distaste for certain 
articles of diet ; or without there being any actual distaste, experience 
shows that certain alimentary matters formerly taken with impunity 
now induce various discomforts. In many cases there is more or less 
loss of appetite, and occasionally this amounts to absolute repugnance 
to all forms and varieties of food. In many cases, again, a persistent 
sense of uneasiness or emptiness, with constant craving for food, is a 
marked phenomenon ; it occasionally happens that the appetite is ab- 
solutely increased ; more frequently, however, the craving is changed 
by the ingestion of even small quantities of food into some other sen- 
sation of discomfort, which brings the meal to a speedy close. In some 
cases, and especially among hysterical females, the appetite becomes 
depraved, the patient not merely craving for aliments which are of an 
unwholesome character, but swallowing earth, coals, chalk, or other 
substances which are either wholly void of alimentary virtues, or 
are disgusting, or absolutely injurious. Thirst may or may not be 
present. 

The abnormal sensations which attend dyspepsia are of different 
kinds. There is generally more or less uneasiness or pain. A sense 
of weight, sinking, fulness, shooting, aching, or burning, referred to 
the pit of the stomach or some neighboring part, or to the inter- 
scapular region, is rarely absent. In some cases this comes on mainly 
when the stomach is empty, and disappears under the influence of a 
meal ; in some it comes on wholly after food, and lasts during the 
whole period of gastric digestion ; in some it is more or less constant, 
being present when the stomach is empty, and becoming aggravated or 
modified after a meal. In other cases pain comes on some little time 
after food has been received into the stomach, it may be in the course 
of a quarter or half an hour, or it may be after a delay of two, three, 
or four hours. Another form of gastric pain is described as also con- 
nected with dyspepsia, a pain of great intensity, frequently likened to 
that of cramp, which comes on at irregular and often rare intervals, 
which lasts a variable time, and is usually attended with marked 
symptoms of faintness or collapse, and often in women with hysterical 
phenomena. This pain, which is not uncommon among gouty persons, 
occupies the usual position of gastric pains, but shoots in various di- 
rections, upwards into the chest and downwards into the abdomen. 
There is no doubt that this variety of gastrodynia is largely con- 
founded with that due to the passage of gallstones, and with pains 
originating in various other than gastric sources. Epigastric tender- 
ness is not usual. 

Flatulence and eructation are generally complained of by dyspeptics 
in a greater or less degree. Flatulence usually goes along with sense 
of fulness or distension of the stomach, and other of the uneasy or 
painful feelings which have been considered. The accumulation of 
gas is indicated also by actual distension of the epigastric region, and 



DYSPEPSIA, 



695 



by the occurrence of gurgling and other noises within the stomach ; 
it moreover gives rise to eructation. Eructation, which is generally 
attended with more or less relief to the patient, is often noisy, and 
effected with powerful and uncontrollable spasmodic action of the 
muscles. The amount of wind thus discharged is sometimes quite 
enormous; and at the same time it is so sudden in its evolution that 
it has been assumed to be secreted by the mucous membrane of the 
stomach and bowels. Of this, however, there is no proof; and indeed 
there can be no doubt that it is really derived from the decomposition 
of the food. The gases consist of carbonic acid, hydrocarbons, and 
in some cases sulphuretted hydrogen. Together with these, small 
quantities of the contents of the stomach are not unfrequently brought 
up. In some cases the quantity of matter thus discharged without 
sensation of sickness and without material effort is very considerable ; 
and the process by which it is returned is then sometimes termed 
rumination. 

Nausea and sickness, again, are frequent symptoms of dyspepsia, 
and are sometimes exceedingly distressing. In many cases of func- 
tional dyspepsia, as in that of pregnancy, nausea often goes along with 
increased appetite. Sickness is usually preceded by nausea, and occurs 
at various times and with various degrees of severity. In some cases 
it comes on when the stomach is empty; more frequently it occurs 
shortly after ingestion ; sometimes it does not happen until an hour 
or two after a meal ; and occasionally it takes place at irregular and 
long intervals. The material vomited presents considerable variety ; 
in some cases it is simply the food but little altered ; in others it is an 
alkaline ropy mucus ; in others it consists mainly of the ordinary acid 
juices of the stomach ; in others it is a neutral watery fluid having 
many of the characters of the salivary secretion. In other instances 
(and especially when the vomiting does not take place until long 
after the ingestion of food) the vomited matters have undergone fer- 
mentation, they are acid from the development of acetic, lactic, and 
butyric acids, and present, on standing, a brownish frothy scum and 
a more or less abundant sediment ; or else they have undergone putre- 
factive changes and have an offensive, sometimes rotten-egg-like, some- 
times almost fecal odor. The vomit presents as much variety in amount 
as in quality ; sometimes it is scanty, and little more abundant than 
occurs in eructation; at other times it is discharged in enormous quan- 
tities ; the latter occurrence is most frequent when the vomiting occurs 
some hours after the taking of a meal, or at irregular and comparatively 
long intervals, and most frequent therefore when there is obstructive 
disease of the pylorus, or when the stomach, from whatever cause, is 
abnormally dilated and sluggish or enfeebled. It may be observed 
that the vomiting immediately after food is generally indicative of irri- 
tability of the stomach ; that the discharge of abundant ropy mucus 
usually implies the presence of inflammation ; that fermentative and 
putrefactive changes point to the long retention of alimentary matters 
in the stomach, and possibly also to some defect of relation between 
the quantity of food ingested and of gastric fluid secreted ; and that 
always after long-continued vomiting the contents of the duodenum, 



696 



DISEASES OF THE DIGESTIVE ORGANS. 



inclusive of the bile, regurgitate into the stomach, and thus mingle 
with the vomit. When fermentation takes place, the torula cerevisioz 
may always be discovered in great abundance in the vomited matters, 
and it is usually under similar circumstances that the sarcina ventriewli 
may also be recognized. 

The term pyrosis is generally used of those cases in which a clear 
fluid is vomited or eructated for the most part in connection with more 
or less severe epigastric pain, and at times when the stomach is empty, 
or nearly empty, of food. The quantity of fluid brought up at one 
time may vary from a few teaspoonfuls to several pints; it is usually 
neutral, but is sometimes alkaline and sometimes acid. Both by 
Budd and by Frerichs this fluid, when of neutral reaction, is looked 
upon as being saliva which has been swallowed. Pyrosis is not un- 
frequently connected with organic disease of the stomach ; but in its 
most typical form is either functional or due to the constant employ- 
ment of certain irritating articles of diet. It is said to be especially 
common among the lower classes in Scotland and Lapland, and to be 
dependent on the quality of their food. 

Symptoms Referable to other Organs. — Among the many secondary 
phenomena of dyspepsia, those connected with the remaining regions 
of the alimentary canal first claim attention. The tongue varies in 
character; it is sometimes clean and healthy, sometimes pale and 
flabby, sometimes more or less thickly coated, and sometimes cracked 
or fissured. The bowels are for the most part constipated, but some- 
times there is persistent diarrhoea, and not unfrequently there is con- 
siderable irregularity of action. In some cases of indigestion, attended 
with looseness of bowels, undigested food in considerable abundance 
is found in the stools. It is obvious that in these cases the passage of 
the contents along the bowel is exceedingly rapid ; and in many of 
them, according to Trousseau, whose experience is confirmed by that 
of Dr. Wilson Fox, there is at the same time large appetite, with rapid 
escape of food from the stomach, and rapid consequent renewal of appe- 
tite. Trousseau assumes that there is excessive irritability of the 
muscular walls of the stomach and bowels, and that it is on this 
account that the food is carried too swiftly onwards. The urinary 
secretion is frequently affected, and may contain an excess of phos- 
phates, oxalates, or urates, the last being not unfrequently deposited 
as a lateritious sediment. The action of the heart is commonly quick- 
ened, but is sometimes slower than natural, and often variable. 
Dyspeptic patients are especially liable to palpitation and irregularity 
of action, coming on not uncommonly after meals or in the night. 
Dyspnoea is apt to attend the attacks of palpitation ; and a variety of 
asthma has been referred to the presence of indigestion. Dyspeptic 
patients are perhaps in a peculiar degree liable to certain forms of skin 
disease, such as urticaria, erythema, lichen, and eczema, but above all, 
perhaps, to acne rosacea, and other allied conditions manifesting them- 
selves upon the nose and cheeks. Elevation of temperature and other 
distinct febrile symptoms are no necessary features of dyspepsia ; but 
they may appear if the dyspepsia be connected with inflammatory 
affections of the stomach. The influence of dyspepsia and of other 



DYSPEPSIA. 



697 



morbid conditions of the stomach on the functions of the nervous sys- 
tem is very remarkable. Vertigo, headache, intolerance of light or 
sound, depression of spirits, irritability, hypochondriasis, sleeplessness, 
and various forms of neuralgia, are all of common occurrence. The 
severer forms of dyspepsia, and especially those in which there is much 
sickness, are usually attended with more or less debility and emacia- 
tion. Indeed, purely functional affections of the stomach, attended 
either with total loss of appetite, or constant vomiting after food, 
occasionally induce a degree of emaciation and debility rivalling that 
which one meets with in the last stages of carcinoma of the cardia or 
of the pylorus, or of pulmonary phthisis with intestinal ulceration. 
On the oiher hand, it is often curious to observe how, notwithstanding 
incessant vomiting, patients retain a fair amount of plumpness. 

Treatment. — The treatment of dyspepsia is a subject of considerable 
importance and of no little difficulty, and demands a good deal of 
firmness, a good deal of savoir faire, a good deal of sound judgment 
and readiness of resource on the part of the physician, and at the same 
time often no little trust and resolution on the part of the patient. 
The first thing to be done is to ascertain as far as may be the circum- 
stances to which the dyspepsia owes its origin x or those which deter- 
mine its continuance, and, if possible, to cure or obviate them. With 
this object, it may be of essential importance to insist on the proper 
comminution of food, to see that the teeth are in good order, and if not 
that they are supplemented or replaced by false ones, or that artificial 
mastication is employed, and that the patient gives ample time to his 
eating; to regulate the distribution of the meals, so that, if they be full 
meals, they shall be separated by intervals of four or five hours at 
least, or if, from any circumstance, the patient is compelled to take 
only small proportions of food at any one time, the intervals between 
them shall be correspondingly reduced; to regulate the quantity of food 
taken at each meal and daily, in the sense of neither letting it fall 
below what is required, nor of permitting any great excess; to insist 
that the food taken shall be wholesome and readily digestible, and that 
especially any article of diet which experience has shown to be injur- 
ious shall be strictly abjured. In reference to diet it may be stated 
that there are considerable differences in regard to the articles which 
are most suitable for different dyspeptics ; and that, in order to treat 
successfully, it is often important to study each patient's peculiarities 
in this respect. It may be stated generally, however, that all rich and 
greasy compounds and fat are likely to disagree; that fish, flesh, and 
fowl (whichever be selected) should be well cooked ; that raw vegeta- 
bles should be eschewed ; that in a large number of cases (and especially 
those in which the stomach is irritable or inflamed) milk and farina- 
ceous foods and eggs are of especial value ; that ripe fruits are admissi- 
ble and often beneficial ; and that alcoholic beverages should be only 
moderately indulged in. In many cases total abstinence from alcohol 
is imperatively demanded. Again, it is always very important to 
ascertain the morbid condition, if there be any, under which the stom- 
ach is laboring; to ascertain if there be inflammation, or ulcer, or 
growth of any kind ; if there be obstruction at the pylorus or at the 



693 



DISEASES OF THE DIGESTIVE ORGANS. 



cardia ; if the stomach be dilated or contracted, and so on ; and to de- 
termine the treatment in accordance with the nature of the lesion which 
is present. It is of equal importance to ascertain whether the dyspep- 
tic symptoms are secondary to any constitutional disturbance, such as 
anaemia, phthisis, or gout, which happens to be associated therewith, 
in order that we may direct our treatment to the relief or cure of the 
essential disease. 

The above remarks are not intended to distract attention in any 
degree from the actual symptoms which cause the patient's sufferings. 
These generally need special treatment; but, guided by the principles 
which have been laid down, we may in most cases so select or so com- 
bine our remedies as on the one hand to relieve local symptoms, on the 
other to remedy the conditions out of which the dyspepsia has arisen. 

Loss of appetite is often very difficult of treatment; it may, however, 
in some cases be overcome by the use of vegetable tonics, especially of 
gentian, quassia, calumba, or the liquid extract of cinchona, in combi- 
nation it may be with small quantities of rhubarb, aromatics. and an 
alkaline carbonate ; or by the employment of quinine or strychnia or 
iron, or (if there be constipation) of aperients, especially rhubarb and 
aloes, in combination with aromatic bitters. But in many cases food 
has to be administered when the patient has not only no desire but 
possibly even a loathing for it. It is then necessary either to study the 
patient's fancies by making frequent variations in the food which is 
placed before him, or to administer food of a wholesome and suitable 
character in small quantities and at short intervals. It is sometimes 
indeed absolutely necessary to employ nutrient enemata, and for a time 
partially or altogether to discontinue the use of food by the mouth. It 
need scarcely be added that appetite usually returns with the restora- 
tion of the normal functions of the stomach, and hence not unfrequently 
without recourse having been had to tonics properly so-called. 

Gastric uneasiness or pain needs different treatment according to the 
circumstances under which it arises or the conditions to which it is 
immediately due. When it occurs mainly during the period in which 
the stomach is empty, the obvious remedy is the ingestion of food ; it 
may then be necessary to take meals at more frequent intervals than 
in health, or to relieve the uneasiness in these intervals by taking a 
biscuit or some other light and easilv digestible refreshment. It not 
unfrequently happens that persons otherwise healthy who have nothing 
after their dinner at five, six, or seven o'clock, wake in the middle of 
the night with more or less gastralgia, or complain of similar pain with 
nausea and perhaps sickness in the morning. The proper treatment 
for such cases is the taking either of a light supper before going to bed 
or of a light meal before rising in the morning. When the pain occurs 
immediately after the ingestion of food it implies the presence of some 
morbid irritability, inflammation, or organic mischief in the walls of 
the stomach, and may be treated partly by regulation and selection of 
diet, and partly by the use of drugs, such as the nitrate of silver, hydro- 
cyanic acid, or bismuth, given before food. If the pain be dependent 
on flatulent distension, peppermint, ginger, and other carminatives are 
generally useful. Mineral acids, and the earthy or alkaline carbonates, 



DYSPEPSIA DIARRHOEA. 699 

are often valuable in relieving pain, as they are in relieving other dys- 
peptic symptoms. It is not always easy to determine apriori which 
remedies are best suited for any particular case. It may, however, be 
assumed as a general rule that, when the secretions of the stomach are 
alkaline or neutral, as they are apt to be in inflammatory conditions, 
acids are indicated; that when they are acid, alkalies, if not specially 
indicated, are at all events more suitable. Opium is of great value in 
the relief of gastric pain, and may frequently be advantageously com- 
bined with other remedial agents, especially perhaps with bismuth. 
When the gastralgia is very severe, and especially if it be of a spas- 
modic character, and associated with faintness or collapse, opium may 
be regarded as our sheet-anchor. It should be given in large, and, if 
necessary, repeated doses. Blisters and other counter-irritants, or fomen- 
tations to the epigastric region are often useful. 

For flatulence and eructation carminatives, and more especially the 
essential oils, some of the oleo- or gum-resins, ammonia, or brandy in 
small quantities are generally beneficial ; but they are beneficial rather 
by assuaging present uneasiness and dispersing wind by eructation than 
by any direct curative influence. For relieving these conditions, how- 
ever, as well as for relieving vomiting, careful attention to the quality, 
quantity, and times of administration of food must always be paid. 

Nausea and vomiting may often be benefited by various agents ; 
by ice in small quantities; by the alkaline carbonates, which may 
often be advantageously given in an effervescing form in combination 
with lemon-juice or citric or tartaric acids; by oxalate of cerium, car- 
bonate of magnesia, lime-water, bismuth, nitrate or oxide of silver, 
hydrocyanic acid or creosote. When the flatulence, eructation, and 
vomiting are dependent on, or associated with, fermentation or putre- 
faction of the contents of the stomach, special treatment may be called 
for; fermentation may be checked by the use of creosote, sulphite of 
soda, or sulphurous acid; putrefaction by the exhibition of the mineral 
acids and more especially hydrochloric acid, with which pepsin may 
be combined, or by what is strongly recommended by many, charcoal. 

In pyrosis or water-brash the above forms of treatment may be ser- 
viceable, but generally bismuth alone or combined with opium, or the 
vegetable astringents conjoined with a narcotic — the compound kino 
powder, to wit — appear to have a special value. In cases in which the 
stomach is excessively dilated it has been proposed to empty the organ 
from time to time by means of the stomach-pump, and then to wash it 
out. 

Lastly, it must never be forgotten that in all cases of chronic dys- 
pepsia hygienic treatment, inclusive of moderate exercise, regulated 
hours, ventilated rooms, and change of air and scene are of extreme 
importance. 



DIARRHCEA. 

The term diarrhoea, like the term dyspepsia, is applied to a symp- 
tom or group of symptoms which are common to a vast range of 



700 



DISEASES OF THE DIGESTIVE ORGANS. 



morbid conditions, of which the majority are discussed with more or 
less completeness in various parts of this volume. It is needless, 
therefore, as well as inappropriate, to enter upon the subject here at 
any great length. 

Causation. — Diarrhoea is of common occurrence at some period or 
other in the course of many febrile or other constitutional maladies. 
It not unfrequently complicates hepatic and splenic diseases, and other 
affections which induce undue congestion of the portal vessels and their 
tributaries. It almost invariably manifests itself as a result of organic 
lesions, of whatever kind, affecting the mucous membrane of the 
bowels. It is very frequently induced by inflammatory conditions of 
this same tract, by the ingestion of unwholesome or irritating articles 
of food, or by overeating. It is certain also that it is sometimes 
caused by nervous influences, and especially by anxiety, fear, and 
allied mental emotions ; and that excessive or perverted secretion from 
the alimentary canal, or from the glands which open upon it, has a 
large share in its production. Among circumstances which exert an 
important influence in causing diarrhoea, are age, habits, season, and 
various other climatic conditions. Thus it is peculiarly frequent 
amongst young children, especially at or about the times of weaning 
and teething, again it, or its converse — constipation — is very apt to 
follow upon dietetic and other changes of habit ; and, further, the in- 
fluence of hot weather, and especially in this country of the later 
summer months, and of alternations of temperature in its causation is 
a well-known fact. 

In considering the pathology of diarrhoea, we may first discuss the 
influence of the contents of the alimentary canal in its causation. It 
is the presence of alimentary matters which, in conjunction with that 
of the normal secretions, excites those peristaltic movements which 
terminate with defecation. The bowels as well as the stomach are no 
doubt in many cases very long suffering ; yet, notwithstanding this, 
they are very frequently stimulated to unwonted action by the matters 
which gain entrance into them. Excess of even wholesome food, the 
ingestion of difficultly digestible or unwholesome matters, the use of 
polluted water, even the transmission from the stomach of imperfectly 
reduced contents, or of such as are undergoing fermentation or putre- 
faction, are all likely to cause more or less intestinal disturbance, with, 
consecutive diarrhoea. Again, excessive discharges from the liver and 
from the intestinal surface, especially if they assume the inflammatory 
character, do, even when themselves determined by the influence of 
irritating alimentary matters, materially promote the abnormal action 
of the bowels. Amongst causes of intestinal irritation must also be 
included prolonged constipation, or excessive accumulation of fecal 
matters. 

Of the important part which the mucous surface of the bowels plays 
in causing diarrhoea there is no room for doubt. It is, in fact, by the 
influence of the contents on this surface that they are themselves influ- 
ential in producing diarrhoea. The conditions of the mucous membrane 
which are present are (omitting morbid growths, degenerative changes, 
and other destructive lesions) irritability, or irritation, or catarrhal in- 



DIARRHCEA. 



701 



flammation. In the first case, the oversensitive surface resents the 
contact of the normal intestinal contents, and excites the muscular 
walls to propel them rapidly onwards ; in the second, the healthy in- 
testinal walls are excited to unwonted action and to oversecretion by 
the irritating matters which are in contact with them ; in the last there 
is actual inflammation present, with more or less important change in 
the character and quantity of the secreted juices. 

Without the action of the intestinal muscular walls, diarrhoea could 
not exist; it is owing indeed to their powerful and frequently-recurring 
peristaltic movements, for the most part refleetorially excited from the 
mucous surface, that the contents of the bowels are carried onwards 
with unwonted energy. It must not be forgotten, however, that the 
action of these muscles is under the direction of the sympathetic nerves, 
and that it is quite possible (as has been proved experimentally) for 
energetic peristalsis to be excited by the direct irritation of these nerves, 
and hence for similar movements to be induced through their agency 
by causes originating in the central nervous organs or other remote 
sources of irritation. Trousseau, indeed, refers one form of diarrhoea, 
as well as one form of dyspepsia which is commonly associated with it, 
to increased tonicity of the intestinal and gastric muscles, a condition 
which, if it exist, is evidently dependent on nervous agency. The in- 
fluence of depressing passions in causing diarrhoea is obviously exerted 
through the nervous system, but whether this operates by simply aug- 
menting peristaltic movement, or in the first instance promoting exces- 
sive flow of mucus and other fluids into the intestinal canal, is a ques- 
tion which it would be somewhat difficult to decide. 

Symptoms and Progress. — By diarrhoea w 7 e mean strictly the actual 
discharge from the anus of unformed or fluid motions in greater quan- 
tity or more frequently than natural. It must not be forgotten, how- 
ever, that, owing in great measure to the remarkable length of the ali- 
mentary canal, and to the variations in its structure and functions in 
different parts of its course, we may have conditions which correspond 
exactly with diarrhoea developed at different parts and leading to dif- 
ferent results. Thus if the affection involve the large intestine, diar- 
rhoea (dysenteric in character) will certainly ensue ; if, however, it attack 
the upper part of the jejunum, the diarrhoea (so to speak) may only 
occur between the jejunum and the ileum, or between these and the 
caecum : the patient will suffer from colic or griping, but instead of fre- 
quent loose evacuations there may be actual constipation. 

As regards the characters of the alvine discharges, there will neces- 
sarily be much variety, dependent partly on the character of the ingesta, 
partly on the amount and quality of the secretions of the various gland- 
ular organs, partly on the fermentative and other changes which take 
place in the bowel, and partly on the rapidity with which the contents 
of the stomach are carried onwards to the anal orifice. We may dis- 
cover in the evacuations solid masses of animal or vegetable matter, fat 
which has not been saponified, comparatively large quantities of only 
slightly modified starch, and in young infants, coagulated but other- 
wise scarcely modified milk. They may contain large quantities of 
mucus, unmixed if it be secreted by the large intestine, incorporated 



702 



DISEASES OF THE DIGESTIVE ORGANS. 



and imparting pallor and fluidity if it be furnished by the remoter por- 
tions of the bowel. Or the discharges may be exceedingly copious and 
almost watery in character, and may contain either large quantities or 
merely traces of biliary coloring matter. It may be observed that the 
fluid condition of the evacuations may be in large measure due to 
simple hurry in the transmission of the contents of the bowels, and to 
the consequent escape with the faeces of those natural secretions which 
under normal circumstances would have been reabsorbed ; there is no 
doubt, however, that in a large number of cases it is dependent in a 
greater or less degree on excessive secretion. When fermentation or 
decomposition occurs there is, attending the diarrhoea, much discharge 
of flatus, which is often exceedingly offensive, and the evacuations, 
which are more or less watery and fetid, present a frothy or yeast-like 
character. Under these circumstances the yeast-fungus or the sarcina 
ventriculi may generally be discovered in them. When the contents 
are propelled along the intestinal canal with great rapidity, there is in- 
sufficient time for digestion, at all events for intestinal digestion, to be 
efficiently performed ; and it is under such circumstances that the con- 
dition termed lientery, or the passage of undigested food, frequently 
takes place. It may be worth while here to call attention to the fact 
that ovarian and other cysts, hydatid tumors and abscesses may open 
into the bowel and give rise to diarrhoeal stools, of which their contents 
form an important and more or less obvious constituent. 

The essential symptoms of diarrhoea are pain and the occurrence of 
loose stools ; but with these are usually associated others of more or less 
severity and importance. Pain of an aching, griping, or colicky char- 
acter is generally present, coming on at intervals, attended with bor- 
borygmi and more or less manifest movements of the bowel, and vary- 
ing in its seat. It differs in severity, and is sometimes so intense that 
the patient rolls about or writhes in agony, and a state of partial col- 
lapse, with coldness of surface, perspirations, and feeble pulse is induced. 
If it be developed high up in the course of the bowel, vomiting not 
unfrequently takes place; if it occur in the lower part of the large in- 
testine, spasmodic expulsive actions of the abdominal muscles are ex- 
cited. There is not usually abdominal tenderness; the pain indeed is 
often relieved by pressure or by friction. In some cases of diarrhoea, 
copious evacuations take place with little or no uneasiness or pain. 
The various characters of the stools have already been detailed. It 
remains to say that the quantities discharged vary within very wide 
limits, and are sometimes as enormous as they are in cases of epidemic 
cholera ; and that the frequency of the evacuations presents equal va- 
riety. Among the associated symptoms which may or may not be 
present, are dryness or coating of the tongue, soreness of the mouth or 
fauces, anorexia and thirst, nausea, vomiting, and eructation, giddiness 
or headache, and, as has been already stated, symptoms of faintness or 
collapse, sometimes alternating with flushes of heat and slight febrile 
symptoms. When diarrhoea is profuse, and at the same time acquires 
a chronic character, innutrition w T ith more or less rapid emaciation and 
loss of strength ensues ; and death may ultimately result either from 
simple exhaustion or from the supervention of complications. 



DIARRHCEA. 



703 



It is scarcely necessary to specify in detail the different characteristic 
features of the many various forms of diarrhoea which are met with in 
practice, or to insist on the extreme difficulty and the frequent impos- 
sibility which there is of distinguishing functional diarrhoea, which is 
now under consideration, from the diarrhoea of intestinal lesions. 
There are, however, two forms of diarrhoea which call for particular 
remark, namely, infantile diarrhoea and summer (English) cholera. 
Although receiving different names it would be difficult to draw any 
clear line of distinction between the morbid conditions here associated. 
We shall, therefore, combine their description. Infants, especially at 
or about the time of weaning, are remarkably apt to be attacked with 
diarrhoea, and to fall victims to it; and this tendency is greatly in- 
creased during the summer months when diarrhoeal complaints are com- 
mon not only in children but in adults. The attack, whether in the 
infant or the adult, sometimes comes on suddenly, sometimes super- 
venes in the course of some slight gastro-intestinal disturbance. It 
usually commences with copious and repeated vomiting, first of the 
normal contents of the stomach, then of more or less abundant watery 
fluid, containing bile. The diarrhoea is at first characterized by the 
expulsion of the contents of the lower bowel but little altered ; but 
gradually the evacuations become more and more thin and watery, 
although still tinged more or less strongly and not unfrequently green 
with the coloring matter of the bile. [The stools in cholera infantum, 
the name by which the disease is best known in America, after the first 
few discharges, which contain fecal matter in greater or less amount, 
usually consist of a thin serous liquid, either alone or holding in sus- 
pension small masses of faeces of a greenish color. They are generally 
very large, indeed they not infrequently, after thoroughly saturating 
the diaper of the child, wet the lap of its mother or nurse. They are 
generally without marked odor, especially when they are colorless. 
Occasionally, however, when they are brownish or yellowish in color, 
they have, according to Meigs and Pepper, a very fetid and offensive 
smell. They may also be very irritating, excoriating the parts with 
which they come in contact.] Together with these phenomena there 
are intense thirst, much pain and griping in the belly, which is usually 
collapsed, not unfrequently cramp in the limbs, and always more or 
less marked collapse indicated by coldness of surface, rapidity and 
feebleness of pulse, pinched features, sunken eyes surrounded by dark 
circles, bluish finger-nails, sighing respiration, altered voice, and rest- 
lessness. The symptoms, in fact, have a close resemblance to those of 
Asiatic cholera, but differ from them clinically in the facts that the 
evacuations rarely, if ever, assume the rice-water character, or are de- 
void of bile ; that the urine is not generally suppressed ; and that the 
collapse is neither so sudden nor so extreme as that of the epidemic 
disease. Nevertheless the affection is very dangerous, carrying off a 
very large proportion of the children whom it attacks, and not unfre- 
quently proving fatal to adults. If recovery take place from the stage 
of collapse, a febrile stage ensues in which the temperature rises, the 
surface assumes a normal or febrile aspect, the tongue becomes red and 
dry, and the evacuations (which probably remain diarrhoeal) acquire 



704 



DISEASES OF THE DIGESTIVE ORGANS. 



something of a dysenteric character. The patient becomes dull and 
lethargic, and, if a child, falls into a condition of stupor, with moaning, 
plaintive cries, and jactitation, which may readily be mistaken for 
symptoms of cerebral disease. The period of collapse lasts from a few 
hours to twenty-four or thirty-six hours; and it is especially during 
this period that death is likely to occur. The later stage may be con- 
tinued for several days or for a week or two. 

[The great mortality from cholera infantum in this country during 
the hot months of the year, renders the disease one of great interest to 
American physicians, especially to those whose practice lies in the large 
cities, where it chiefly, indeed almost exclusively, prevails. Among 
its causes are unquestionably improper food and the intense heat of the 
summer, a heat, too, which continues with almost undiminished in- 
tensity during the night. But that these alone are not sufficient to 
produce it is shown by the fact that is of comparatively very in- 
frequent occurrence in the country, in the neighborhood of the cities, 
where the temperature is almost equally high, and where the diet is 
often unsuitable. It is therefore probable that among the other causes 
which co-operate with these are bad drainage, imperfect ventilation, 
and overcrowding. 

When the large number of children who annually fall victims to 
this disease is taken into consideration it is rather surprising that so 
few post-mortem examinations are on record. Dr. J. Lewis Smith, of 
New York, who has enjoyed unusual opportunities for its study, has 
found evidences of inflammation of the whole of the gastro-intestinal 
tract, together with enlargement of the solitary glands, and in many 
instances of Peyer's patches. He therefore attributes the symptoms to 
these lesions. On the other hand, Drs. Meigs and Pepper, adopting Dr. 
Sedgwick's theory of the pathology of cholera, and believing that 
symptoms closely resembling those of cholera collapse may be pro- 
duced by various morbid conditions of the intestines, or by the inges- 
tion of unwholesome or tainted food, including milk which has 
undergone change, teach that the collapse in cholera infantum is 
attributable to a wide-spread and powerful irritation of the branches 
of the sympathetic distributed to the mucous membrane of the bowels. 
This theory explains, as it does in cholera, many of the principal 
symptoms of the disease, such as the coldness of the surface, the small, 
thready, and frequent pulse, the pinched features, the hollow eyes, the 
attacks of cramp, the cold breath, and the occasional suppression of 
the urine. 

It is of the greatest importance to guard children against attacks of 
cholera infantum. This is most effectually done by sending them out 
of town during the hot weather whenever the means of their 
parents will permit it, or if they do not, by insisting that they shall 
spend as much time as possible in the open air, and be sent upon short 
excursions into the country. In addition to this, their diet should be 
carefully regulated, all overcrowding prevented, and imperfect drain- 
age or ventilation corrected. If these precautions are taken attacks 
may often be averted. But even after the child is actually taken sick 
it should be removed if possible from the town, preferably to the sea- 



DIARRHCEA. 



705 



coast, sea air under these circumstances often exerting a wonderful 
influence for good. If too ill to bear a long journey, or if circum- 
stances render this impossible, it should be carried to the squares or 
parks of the city, and allowed to remain there for several hours. Even 
desperately ill children will often show signs of improvement while in 
the open air. 

The diarrhoea, with which the disease is usually ushered in, should 
never be allowed to run on without an attempt being made to check 
it. Small doses of calomel, from to J of a grain, according to the 
age of the patient, administered every two or three hours, will often 
have a happy effect in controlling this symptom as well as the ten- 
dency to vomit. At other times the aromatic syrup of rhubarb, either 
alone or with chalk mixture, will be found to be a useful remedy. 
Later chalk mixture and an astringent, such as tincture of rhatany, 
may be given. When collapse has occurred it will be necessary to 
stimulate the patient. This may be done by giving a few drops of 
brandy, either alone, in milk, or in combination with sulphuric acid 
and morphia, but the last-named drug must be given in very small 
doses and with extreme care, as experience has shown that it is a 
dangerous remedy in this disease. Attempts may also be made to 
rouse the cutaneous circulation by the application of mustard plasters 
to different parts of the surface of the body, especially the abdomen. 
When the skin is hot and dry, relief is often afforded by cold bathing 
or sponging. 

Other remedies are tannic acid, bismuth, pepsin, nitrate of silver,^ 
and acetate of lead; a combination of bismuth and pepsin yielding ex- 
cellent results when the stools contain undigested food. During con- 
valescence tonics should be prescribed, and among them the tincture of 
the chloride of iron may be mentioned as especially useful. 

If there is no vomiting the child, if it has been weaned, should be 
allowed milk either alone or made up with arrowroot, given in small 
quantities frequently repeated. If this be rejected the milk may be 
given diluted with an equal bulk of lime-water, or what is in many 
cases better borne, weak chicken tea may be administered. It will 
occasionally be found necessary to have recourse to beef tea or to 
Valentine's extract of beef. As improvement takes place the diet may 
be increased, but this should be done very guardedly.] 

Treatment. — The treatment of diarrhoea must depend mainly upon 
the causes to which it is due and the symptoms with which it is at- 
tended. When it is distinctly the consequence of alimentary errors, 
it is usually best at the commencement to aid the removal of offending 
matters either by emetics, such as mustard and water or a full dose of 
ipecacuanha, or by purgative medicines such as hyd. c creta, blue pill, 
Gregory's powder, compound rhubarb pill, an ordinary black draught, 
or castor oil. Such measures may effect a cure; but if the diarrhoea 
still persist carminatives and astringents may be requisite. Of such 
remedies the compound kino powder, the aromatic chalk and opium, 
the chalk mixture, or lime-water or bismuth combined with vegetable 
astringents, opium or rhubarb, may be efficacious. If these fail re- 
course may be had, according to circumstances, to tannic acid, lead and 

45 



706 



DISEASES OF THE DIGESTIVE ORGANS. 



opium, copper, perchloride of iron, nitrate of silver, or sulphuric acid. 
An essential element in the treatment, however, and one which is alone 
often sufficient for the purpose, is partial or complete abstinence from 
food for a time, and the subsequent limitation of the patient's dietary 
to such matters as are bland and easily digestible. Milk, arrowroot, 
and such-like substances, broths, toast, and simple well-baked biscuits 
are especially suitable. In the case of young children no purgative 
medicines probably are better than the chalk and mercury, Gregory's 
powder and castor oil ; and no combination of astringents and aro- 
matics better than the aromatic chalk and opium, or small quantities 
of catechu, opium, aromatic chalk, and syrup of ginger in solution. 
In this case, too, especial attention must be paid to diet. If the child 
has been weaned it may be necessary to supply it again from the 
breast ; or to provide it with asses' or goats' milk ; or to feed it with 
skimmed cow's milk to which lime-water may be added ; or with well- 
baked flour or suitable biscuit-powder diffused or suspended in water 
or milk. If the diarrhoea be of distinctly inflammatory origin very 
much the same kind of treatment is needed ; purgatives may still be 
requisite in the early stages, but saline purgatives or castor oil are 
probably then preferable. Dietetic treatment also in these cases is of 
paramount importance. If there be much abdominal uneasiness or 
griping, warm fomentations, or mustard plasters to the parietes, or the 
warm bath may be beneficial. 

In the choleraic form of diarrhoea, which attacks young children 
and adults, mainly in the summer time, little or nothing can be done 
at first to arrest the diarrhoeal phenomena. Trousseau regards the 
mustard bath (made by inclosing a cold paste of mustard in a muslin 
bag and squeezing this in the water of the warm bath until the latter 
is sufficiently impregnated) as the most powerful and efficacious remedy, 
and directs that it should be employed for about a quarter of an hour, 
or until the mustard causes some tingling of the surface, and that it 
should, if necessary, be repeated. For internal treatment the exhibi- 
tion of iced water or of rice-water, or decoction of barley, or skimmed 
milk, or the eau albumineuse of Trousseau, made by diluting the whites 
of four eggs with about If pints of water, sweetened with sugar and 
flavored with orange-flower water, may be resorted to with advantage. 
During the same period emetic doses of ipecacuanha, and purgative 
doses of the hyd. e creta are of common use and strongly recommended ; 
but if the collapse be serious, diffusible stimulants, such as ether and 
ammonia, or some form of alcoholic beverage, are demanded. At this 
period opium is a remedy of more than questionable efficacy, and in 
the case of young children should be carefully avoided. With the 
cessation of diarrhoea and vomiting and the supervention of febrile 
symptoms the diet above recommended must still be continued, but 
the medicinal treatment must now be that which is beneficial in ca- 
tarrhal inflammation of the bowels, and may include such drugs as 
bismuth, chalk, and lime-water, with opium. 

Chronic diarrhoea is often very intractable, and requires much judi- 
cious management for its successful treatment, hence attention to diet 
is of supreme importance. It is impossible, however, to lay down any 



DISEASES OF THE LIVER. 



707- 



definite rules in reference thereto. In many cases fluid nutriment' is 
most suitable, in some food is best administered in the solid form, in 
some the farinacea agree best, in some alimentary matters derived 
from the animal kingdom. We must be guided in each case partly by 
the patient's own feelings and experience, partly by the special symp- 
toms present and the characters of the evacuations, and partly, of 
course, by the opinion which we form of the nature and origin of the 
attack. In such cases it not unfrequently happens that the diarrhoea 
is kept up by the constant use of some unsuitable article of diet, or by 
the constant presence of some hygienic condition inimical to the pa- 
tient's health, or by the indulgence in habits which are injurious to 
him. It is in chronic diarrhoea (especially in children) that the use of 
raw meat, to the exclusion of all other food, has been so strongly advo- 
cated. The lean of beef or mutton should be selected, minced, pounded 
in a mortar, and then squeezed through a sieve, and given either in 
the form of the simple pulp, or mingled with sugar, red-currant jelly, 
or other similar substances. It should be administered in small doses 
at first, and then be gradually increased. Trousseau has given at 
length as much as a pound a day to a child of less than three years 
old. In giving raw meat we must not forget the danger which our 
patient incurs of becoming affected with taenia, a danger which both 
Trousseau and Goodeve have shown not to be fanciful. For medicinal 
treatment we may have recourse to the various vegetable astringents 
and bitters, or to bismuth, silver, copper, or iron, or to the mineral 
acids, or to rhubarb, or ipecacuanha, or opium, nor must we forget the 
benefit which may result from the occasional administration of the 
saline or of the stomachic purgatives. 



(4.) — DISEASES OF THE LIVER. 

INTRODUCTORY REMARKS. 

Anatomical Relations. 

In investigating hepatic diseases, a careful examination of the hepatic 
region should not be neglected. The healthy liver occupies the right 
hypochondrium, extending across the scrobiculus cordis into the left 
hypochondrium, and throughout this extent is accurately adapted to 
the vault of the diaphragm. In the recumbent posture the lower edge 
is usually concealed by the lower margin of the right side of the chest, 
except in the upper part of the epigastric region, where small portions 
of the right and left lobes lie uncovered. The position of this edge 
varies, however, during respiration, descending somewhat in inspira- 
tion, ascending again in expiration ; it descends also to a slight extent 
when the sitting or upright posture is assumed. Moreover, in women 
who lace tightly, and occasionally in other healthy persons, it may be 



708 



DISEASES OF THE DIGESTIVE ORGANS. 



found as much as two or three inches below the margins of the ribs. 
In some cases, on the other hand, it occupies normally a higher posi- 
tion than usual. The upper limit of the liver necessarily corresponds 
to the position of the diaphragm with which it is in contact, and is 
higher, therefore, on the right than on the left side. The upper'mar- 
gin, however, of that area of the upper surface which is covered super- 
ficially by the diaphragm and thoracic walls only occupies a lower 
level, corresponds to the lower and outer margin of the right lung, and 
varies with the varying positions of that margin. Adopting Frerichs's 
estimates, it may be assumed that (liable to more or less variation), in 
the nipple line, the true upper boundary of the liver corresponds to the 
fifth interspace, the line of separation between the edge of the lung and 
the liver to the sixth rib; in the axillary line, the former to the seventh 
interspace, the latter to the eighth rib ; and near the vertebral column, 
the former to the tenth interspace, the latter to the eleventh rib. It 
must be added that all that region to which the liver is immediately 
subjacent is dull or nearly so on percussion, and that in front and to 
the left the upper part of that region merges in the cardiac area, and 
below and behind in that of the right kidney. General increase in the 
bulk of the liver is attended both with the ascent of the upper margin 
of the hepatic area into the chest, and with the descent of its lower 
margin into the abdomen, the latter being necessarily the more consid- 
erable. The lower margin can then be generally well distinguished, 
with all its characteristic peculiarities of outline. In some cases it 
descends into the iliac and hypogastric regions. When, however, the 
increase of the liver in bulk is irregular, or due to the presence of 
tumors, in some cases the enlargement is wholly at the expense of the 
thoracic cavity, and the walls of the lower part of the right side of the 
chest may be distinctly protruded over it; in other cases the enlarge- 
ment takes place mainly in the direction of the abdominal cavity, and 
the irregularity of form of the affected organ may then be readily dis- 
tinguished through the abdominal walls. When the liver becomes 
diminished in size, the area of its dulness correspondingly diminishes, 
and sometimes wholly disappears. Occasionally, moreover, under these 
and other circumstances, the intestines rise up and intervene between 
the liver and the parietes. 

Physiological Considerations. 

In entering upon the subject of the diseases of the liver it is of ex- 
treme importance that we should have some preliminary acquaintance 
with the nature of the functions which this organ has to perform, and 
on the disturbance or modification of which many of the more im- 
portant or striking phenomena of hepatic disease necessarily depend. 
In the very brief review of this subject, which we are now about to 
place before the reader, we shall avail ourselves largely of the masterly 
summary given by Dr. Murchison in his work on the functional de- 
rangements of the liver. 

The liver appears to have at least three important and more or less 
distinct offices to fulfil. First, starchy and saccharine matters, brought 



DISEASES OF THE LIVER. 



709 



to it by the portal vessels from the alimentary canal, are converted by 
it into glycogen (C 6 H 10 O 5 ), a substance resembling dextrin, and con- 
vertible, like it, into sugar by the action of albuminoid ferments. 
Glycogen is formed and stored in the hepatic cells, whence (especially 
during the intervals of fasting) it is removed in the form of sugar by 
the hepatic veins, and then distributed : partly for the maintenance of 
heat, to be converted in the lungs into carbonic acid and water: partly 
to take an important share in the growth, development, and functional 
activity of cells, and probably even in the development of the white 
corpuscles of the blood. Further, glycogen is probably convertible 
into fat, and may, under certain circumstances, be the source of accu- 
mulation of oil in the hepatic cells, or of adipose deposition in other 
parts of the body. Second, albuminous matters, whether derived di- 
rectly from the food, or constituting an essential part of the blood, and 
especially fibrin, appear to become reduced, through the agency of the 
liver, into various simpler compounds. These include glycogen, the 
destination of which has been already considered, and effete matters, 
such as leucin (C 6 H 13 N0 2 ) and tyrosin (C 9 H u N0 3 ), which are ulti- 
mately resolved into uric acid (C 5 H 4 N 4 0 3 ), and more particularly into 
urea (CH 4 N 2 0), and then discharged with the urine. Urea itself ap- 
pears, at all events to some extent, to be manufactured in the liver. 
Third, the liver secretes bile. This is a thin, transparent, golden-yel- 
low fluid, which becomes viscid and assumes a darker color in the gall- 
bladder in consequence of its admixture with mucus. Roughly speak- 
ing, about two pints of bile are secreted daily by a healthy adult, of 
which from 9 to 17 parts per cent, consist of solid matters. These 
comprise small though varying proportions of mucus, fat, salts, and 
various compounds due to the disintegration of albuminous substances, 
but mainly certain ingredients of special interest and importance, namely, 
resinous acids in combination with soda, coloring matter, and choles- 
terin. The resinous acids, which are two in number, are the glyco- 
cholic and the taurocholic ; they are both conjugate acids, the former 
being formed by the union of glycocoll (C 2 H 5 N0 2 ) with cholic acid 
(C 24 H 40 O 5 ), the latter by the union of glycocoll with taurin (C 2 H 7 N0 3 S). 
This latter acid contains all the sulphur of the bile, and to it the bit- 
terness of this fluid is due. The peculiar color of the bile is owing to 
the presence of a pigment now termed bilirubin (C 16 H 18 N 2 0 3 ). This 
readily undergoes oxidation even in the gall-bladder, becoming suc- 
cessively yellow, green, brown, and black. Bilirubin crystallizes in 
ruby-colored, rhomboidal crystals, which are scarcely, if at all, distin- 
guishable from hsematoidin crystals, but chemically are said to contain 
one atom more of carbon. Cholesterin forms a small but constant 
part of the solid constituents of the bile, and is usually the main con- 
stituent of biliary calculi. As regards the sources of the essential in- 
gredients of the bile, it has been maintained by some that they are, like 
urea, formed in the blood, and simply separated from it by the liver; 
by others that they are a product of that disintegrating power which 
the liver itself has over the albuminous and other matters which are 
brought within its influence. The latter view is now generally accepted. 
Taurocholic and glycocholic acids appear, therefore, to be products of 



710 



DISEASES OP THE DIGESTIVE ORGANS. 



that disintegration of albuminous substances to • which reference has 
been already made ; and bilirubin to be a derivative of the coloring 
matter furnished by disintegrating blood-corpuscles. It has been sug- 
gested by Dr. Austin Flint, Jr., that the cholesterin of the bile is to be 
traced to the disintegration of nervous tissue, and that one of the chief 
functions of the liver is the separation of this fatty matter from the 
blood. The purpose aud destination of the bile have been equally a 
matter of dispute. There is little doubt, however, that the bile is an 
important agent in the saponification and absorption of fats, and even 
in the assimilation of albuminous matters, and further, that it promotes 
peristaltic action, and arrests decomposition. It is certain that it is 
only in some small degree excrementitious, the great bulk of it, like 
saliva and gastric juice, being reabsorbed, in a more or less modified 
condition, into the system. The excrementitious parts comprise por- 
tions of the coloring matter and of the cholic acid, and certain deriva- 
tives of cholesterin. The parts which are reabsorbed comprise the 
taurin, the glycocoll, the greater part of the cholic acid, and a con- 
siderable proportion of the coloring matter ; which last, there is reason 
to believe, becomes converted into the coloring matter of the urine. 

Pathological Considerations. 

It will be readily understood from the above observations how numer- 
ous and how various are the ways in which diseases of the liver may 
affect the nutritive and other processes of the body, and how numerous 
and various are the symptoms to which they may give rise. Diabetes 
has long been regarded as a functional affection of the liver ; and Dr. 
Murchisou attributes to functional disturbance of the same organ not 
only gout, renal calculi, and biliary calculi, but a large proportion of 
the functional and structural derangements of nearly all the organs 
and tissues of the body. The most striking, if not the most important 
results of hepatic diseases, however, are those which are connected with 
derangement or suppression of the biliary secretion, namely, jaundice, 
and various associated phenomena, which will presently be fully con- 
sidered. 

A further consequence of structural disease of the liver, or of any 
disease implicating the trunk of the portal vein, is impediment to the 
ready flow of blood through this vessel or through its branches of dis- 
tribution to the liver, and hyperemia of the tributary vessels connected 
with the other chylo-poietic viscera. This hyperemia leads to various 
mechanical consequences, especially to permanent dilatation of the 
vessels, which when occurring in the vicinity of the anus constitutes 
haemorrhoids ; to haemorrhage more or less profuse from the mucous 
surface of the alimentary canal ; and to abdominal dropsy. 

Jaundice. — This is due to the circulation with the blood, to the de- 
position in various tissues, and to the separation, through the agency 
of certain unwonted emunctories, of the coloring matter of the bile, 
and its various modifications. But, as we have pointed out, the bile 
contains other ingredients besides coloring matter, and the hepatic 
cells have other functions to perform besides the mere manufacture of 



DISEASES OF THE LIVER. 



711 



bile. It is obvious therefore that the existence of jaundice — the circu- 
lation of biliary coloring matter — -almost necessarily involves the cir- 
culation of those other ingredients of the bile which are less readily 
detected, and probably also the presence in the blood in greater or less 
abundance of various effete derivatives of albuminous matters. 

But what is the explanation of the accumulation of biliary coloring 
matter in the blood ? By those who hold that the liver excretes bili- 
rubin and the other constituents of the bile exactly as the kidney ex- 
cretes urea, jaundice is attributed to loss or diminution on the part of 
the liver of its dialyzing power. There is ample evidence, however, 
from the results of the removal of the liver in the lower animals, that 
bile is not formed in the blood, and that as a general rule the presence 
of the liver is essential to the production of jaundice. It is certain also 
that when jaundice follows the experimental obstruction of the hepatic 
ducts, it first manifests itself in the hepatic cells, and then in the lym- 
phatic vessels which take their origin in the liver, facts which clearly 
demonstrate that in this case at all events the jaundice is due to the 
passage into the general circulation of coloring matters manufactured 
in the liver. It has hence been assumed, and doubtless with truth, 
that in those cases in which jaundice is due to obstruction, the coloring 
matter of the bile formed in the cells is absorbed both from the cells, 
and from the hepatic ducts behind the seat of obstruction, by probably 
both the hepatic venous capillaries and the lymphatics, and thus be- 
comes distributed throughout the system. It has also been assumed, 
but on a far less substantial basis, both by Frerichs and by Murchison, 
that jaundice may arise, in cases of prolonged constipation and in cases 
of excessive secretion of bile, from absorption taking place at the mucous 
surface of the bowel. 

But if the hepatic cells are in a condition to manufacture bilirubin 
they are doubtless also in a condition to manufacture the biliary acids. 
What, then, becomes of these? They are absorbed, together with 
biliary coloring matter, and mingle with the circulation, but what be- 
comes of them further is still a matter of dispute. Dr. G. Harley and 
others assert that they accumulate in the blood, and are discharged 
with the urine, in which fluid they may be detected by appropriate 
means. Frerichs, on the other hand, and Dr. Murchison agrees with 
him, believes not only that they are never found in the urine, but that 
in the blood they speedily undergo chemical changes, and their identity 
becomes lost. Frerichs, it may be added, believes that the reabsorbed 
biliary acids may be converted into biliary pigment, and that hence 
their absorption may increase jaundice if it do not absolutely create it. 

But, even if it be admitted that the above explanation holds good 
of all those cases in which jaundice is due to obstruction of the hepatic 
ducts, and that it may be extended to cases of jaundice (if there be 
such) referable to intestinal obstruction, or to excessive production of 
bile, it is clearly inapplicable to some, at all events, of those cases in 
which (as in pyaemia and certain of the infectious fevers) jaundice is an 
item of a general disease, and to the cases in which (as probably in 
malignant jaundice) the icteric tinge is associated with the destruction 



712 



DISEASES OF THE DIGESTIVE ORGANS. 



of the secreting cells of the liver, and their consequent inability to dis- 
charge their specific functions. The close relationship of the coloring 
matter of the blood to that of the bile, and the facts that the latter is 
derived from the former, and that both yield parallel series of almost 
identical colored derivatives, make the view which Virchow strongly 
advocates — namely, that in many of these latter cases, jaundice is due 
not to the agency of the liver, but to changes in the haeraatin effected 
in the general circulation — both highly probable and easy of acceptance. 
Frerichs, however, even in reference to some of these cases, prefers to 
believe that the jaundice is due to the absorption of the elements of 
the bile at the mucous surface of the bowel and to interference with 
the due course of those changes which the reabsorbed bile should 
undergo in the blood. 1 It is important to add that when, as in malig- 
nant jaundice, the secreting structure of the liver is destroyed, the 
jaundice is not usually intense, and the biliary acids are certainly never 
detected in the urine, while on the other hand, the retrograde metamor- 
phosis of albuminous matters remains incomplete, and leucin and tyro- 
sin which accumulate in the blood, replace more or less completely urea 
in the urine; and that, according to Dr. G. Harley, Kiihne, and others, 
when jaundice is the result of obstruction, the biliary acids may be 
recognized in the urine, and that their recognition there may be taken 
as a proof of the obstructive origin of the jaundice. 

The phenomena which attend and indicate jaundice, and the conse- 
quences which flow from it are very various, but may be pretty readily 
enumerated. 

1. There is usually a greater or less deficiency of bile in the alvine 
evacuations, and more or less consequent tendency to constipation, flatu- 
lence, fetor of the evacuations, faulty assimilation, especially of fat, and- 
distaste for fat. If the bile be wholly absent, these phenomena are 
more strongly marked, and the faeces acquire a chalky or gray or slaty 
color, or assume some tint referable to the prevailing character of the 
patient's diet. It may be added that diarrhoea sometimes comes on, 
and that fatty matters, but little altered, are apt to pass away with the 
evacuations. 

2. Omitting for the present all reference to the changes taking place 
in the liver itself, the coloring matter of the bile first accumulates in 
the blood, then it commences to escape with the urine, and subsequently 
gradually tinges the conjunctivae and the skin, passing off at the same 



1 [French's theory may be briefly stated as follows : The biliary acids are in part 
directly absorbed into the blood either by the hepatic vein or by the veins of the 
intestines, and are in health converted through oxidation into taurin and the urinary 
coloring matter. In some forms of disease, however, these acids are incompletely 
oxidized, and then are changed into bile-pigment I)r. Murchison teaches, on the 
other hand, that absorption of the bile-pigment as well as of the acids is all the time 
going on in the intestines; but that under normal circumstances its accumulation 
in the blood in such quantities as to cause discoloration of the skin is prevented by 
its transformation into other substances. If this metamorphosis be interfered with 
from any cause, jaundice will occur. In this way he explains the icterus which 
follows the introduction of certain poisons into the blood, or that which appears in 
the course of some of the fevers, or is the result of nervous influences, as fear, pas- 
sion, and the like.] 



DISEASES OF THE LIVER. 



713 



time in some small degree with the sweat. Other parts which become 
bile-stained are the serous membranes and all effusions which take 
place in connection with them, the connective and the fibrous tissues, 
the fat, the muscles, and the bones. The mucous membranes are as a 
rule scarcely affected, and the secretions from their surfaces and from 
the various glands which open upon them are usually entirely free. 
The brain and nerves remain for the most part uncolored. The only 
secretions besides those of the kidneys and sudoriparous glands, which 
have certainly been found to contain bile, are that of the mammary 
gland and those furnished by inflamed mucous surfaces. Superficial 
jaundice first shows itself in the conjunctivae, but soon becomes gener- 
ally diffused throughout the whole cutaneous surface. It is at first a 
mere condition of sallowness, but soon assumes a saffron or golden 
yellow hue, and if long continued, a brownish, olive, or bronze-like 
tint. The seat of the discoloration is mainly the rete mucosum and 
the sudoriparous glands. The secretion, indeed, of the latter some- 
times becomes so largely charged with bile-pigment as to stain the 
linen. The usual characteristics of bilious urine, and the tests for the 
recognition of bile-pigment in that fluid are elsewhere considered. It 
may, however, be pointed out here that the urine varies in color from 
a saffron-yellow to a peculiar greenish or brownish black, that its froth 
always presents a peculiarly yellow hue, that it stains white paper and 
linen, and, further, that it is generally free from sediment, transparent, 
and acid. It is apt, however, to present other peculiarities, of which 
some have been already adverted to ; it occasionally yields uratic or 
other deposits ; it may possibly, when the jaundice is obstructive, con- 
tain bile acids ; it certainly displays, in the presence of extensive 
destruction of the hepatic cells, a remarkable diminution of urea and 
of phosphates, and in their place a great abundance of leucin and 
tyrosin, which then sometimes fall as a greenish-yellow sediment; 
and, lastly, there is often, especially towards the fatal close, either gly- 
cosuria or albuminuria, or both. Albuminuria is probably connected 
with the irritation caused by the long-continued passage of bile-pigment. 
All the tissues of the kidneys gradually become very deeply stained, 
more especially the cells of the convoluted and of the straight tubes ; 
and the canals of the tubes are not unfrequently found to be occupied 
by granular or amorphous pigmented casts which become shed and 
may be found in the urine. 

3. There are a number of other phenomena occasionally associated 
with jaundice, of which some are interesting, others are of grave im- 
portance. It is asserted that sometimes all objects appear yellow to 
jaundiced patients. But this occurrence is certainly rare, and the 
explanations which have been given of it are conflicting. There is 
often troublesome, and sometimes unbearable, itching of the skin. 
This is not generally attended w T ith obvious eruption ; but occasion- 
ally we find lichen or urticaria, or some one of the different varieties 
of erythema multiforme. Vitiligoidea or Xanthoma is well known to 
be frequently associated with chronic jaundice. The action of the 
heart is usually much enfeebled, and often reduced in frequency; there 
is also a marked tendency to the occurrence of haemorrhage, revealing 



714 



DISEASES OF THE DIGESTIVE ORGANS. 



itself by the appearance of petechia, or by epistaxis or gastro-intestinal 
or other fluxes, which may be so copious, or so frequently repeated, as 
to prove fatal. Together with these symptoms the patient usually be- 
comes emaciated and feeble, irritable or low-spirited, and little capable 
of resisting the influence of either mental or bodily fatigue or of in- 
clemency of the weather. 

It is not surprising that patients suffering from jaundice should 
sooner or later present impairment of nutrition and other indications 
of profound ill-health. It is surprising rather that they should live 
as long as they occasionally do, and yet present so few symptoms and 
undergo so little suffering; and that bile itself should, as has been 
shown by experiment, have so little injurious influence over the blood 
and over the various corporeal functions. Occasionally, however, 
symptoms of so-called " bilious toxaemia " arise. They seem however 
to occur mainly, if not solely, in those cases in which the jaundice is 
connected with destruction of the hepatic cells, in which urea tends to 
disappear from the urine, and leucin, tyrosin, and other products of 
albuminous decomposition circulate with the blood and find their way 
into the urine. And, indeed, the toxemic effects seem to be due not 
to the influence of the elements of bile, but to those of the various ex- 
crementitious matters, of which leucin and tyrosin are probably the 
most important. The symptoms here referred to comprise, in the first 
instance, headache, restlessness, mental depression or excitement, and 
sense of illness, then busy or violent delirium, or else convulsions, 
varying from mere rigors to general epileptiform attacks or tetanic 
spasms, or delirium and convulsions intermingled, and finally stupor, 
passing into coma and death. 



HEPATITIS. HEPATIC ABSCESS. CIRRHOSIS. 

Causation. — It is not easy, nor is it important clinically, to distin- 
guish congestion from inflammation of the liver, and we shall therefore, 
include those two conditions under a common description. Simple 
congestion of the liver may be due to mechanical obstruction to the 
flow of blood through the heart or lungs, or to overfeeding. Inflam- 
mation may originate in the same conditions, but may be produced also 
by various other causes, among which may be enumerated mechanical 
injuries, the presence of foreign bodies in the liver, exposure to vicissi- 
tudes of temperature (more especially in hot climates), the ingestion of 
too stimulating articles of diet, and especially of alcoholic drinks, and 
the malarious poison. It occurs also in connection with some of the 
infectious fevers, and with pyaemia ; and occasionally involves the liver 
by extension from neighboring parts. It is believed by many, as has 
been taught by Dr. George Budd, that hepatic abscesses are often due 
to purulent absorption taking place from ulcerated surfaces in venous 



HEPATITIS. 



715 



connection with the portal system of vessels, and that especially the 
hepatic abscesses which are associated with dysentery have such an 
origin. We have discussed elsewhere the connection between dysentery 
and hepatic abscess. 

Morbid Anatomy. — 1. Congestion and Simple Inflammation. — Hy- 
peremia of the liver is not uncommonly observed after death, and 
doubtless is not unfreqnent during life. The organ is enlarged and 
presents a more or less dark-red hue, the hepatic veins are full of blood, 
and blood escapes pretty freely from the cut surface. This condition 
may be general or limited to certain regions only. The most charac- 
teristic form of hyperemia is that which attends obstructive diseases of 
the heart or lungs. In the early condition of this affection it is not 
improbable that the congestion is more or less uniform ; but after it has 
been maintained for any length of time changes, some of which are 
secondary to the congestion, manifest themselves in the liver, and this 
then assumes the well-known nutmeg character. In this state the liver 
is enlarged, and often somewhat granular, with a more or less thick- 
ened capsule ; it presents some degree of induration, and on section the 
surface is found to be closely studded with small circles or festoons of 
an opaque buff-colored or bright yellow material, interwoven with disks 
or small lobulated patches of intense, perhaps black, congestion. The 
appearance has been not inaptly compared to that presented by the sec- 
tional surface of a nutmeg, and is due to the fact that the peripheral or 
portal portions of the hepatic lobules are more or less loaded with oil. 
and at the same time probably jaundiced, while the ceutral or hepatic 
venous portions of the lobules are free from oil and deeply congested. 
In association with these changes there is usually, after a time, not only 
considerable permanent dilatation of the smaller branches of the hepatic 
veins within the lobules, but atrophy and disappearance of the hepatic 
cells occupying the same regions. 

Inflammation in the liver, as in other organs, affects mainly the con- 
nective tissue and the small vessels in the meshes of which the proper 
elements of the gland are contained. The vessels become dilated and 
full of blood with a superabundance of leucocytes ; the tissues get infil- 
trated with inflammatory exudation, and a development of embryonic 
tissue takes place in the walls of the small vessels, and in their imme- 
diate vicinity, and generally in the connective tissue. At the same 
time it may happen that the proper cells of the liver become swollen 
and cloudy and even the seat of fatty deposition. The appearances 
presented by the inflamed tissues differ widely in different cases, mainly 
in dependence on the causes to which the inflammation is due and on 
its intensity. In some cases the most marked features are uniform 
opacity and lightness of tint, with doughiness of consistence, and en- 
largement of the lobules. These peculiarities are due to the fact that 
the hepatic cells have become cloudy and swollen; while, in some 
measure owing to this very circumstance, there is but little inflamma- 
tory exudation present, and the vessels contain but little blood. When 
a limited portion of liver is thus affected the pallid and swollen patch 
is usually surrounded by a more or less diffused area of congestion ; 
when the whole organ is implicated, the pallor may be universal, or 



716 



DISEASES OF THE DIGESTIVE ORGANS. 



it may be marbled with patches of congestion. As will be hereafter 
shown, there is reason to believe that the condition known as yellow 
atrophy of the liver is probably an inflammation of the kind here re- 
ferred to. 

2. Inflammation of Ducts. — Inflammation not unfrequently begins 
in the mucous membrane of the hepatic ducts, most commonly involv- 
ing them by extension from the duodenum. It is generally catarrhal, 
and indicated by an excessive discharge of ropy mucus, and by a 
swollen condition of the mucous membrane itself; and these phenomena 
not unfrequently lead to more or less complete obstruction. Such ob- 
struction usually occurs in the common duct, and especially in that 
part of it which is embraced in the intestinal walls ; it is generally 
temporary, subsiding in the course of two or three weeks or less, but 
sometimes results in organic stricture, and sometimes in permanent 
closure, or in closure which is relieved only by the supervention of 
more or less extensive ulcerative destruction. In some instances a 
false membrane forms upon the mucous surface, and occasionally polypi 
or papillary growths are developed. The most remarkable conse- 
quences of catarrhal inflammation are those which are immediately 
dependent on mechanical impediment to the escape of bile, and which 
are therefore associated from the beginning with mechanical distension 
of the ducts. These are suppuration or abundant haemorrhage from 
the congested surface, ulceration, and more or less extensive destruc- 
tion of the mucous membrane. 

3. Suppuration. — In many cases where the inflammation is circum- 
scribed and at the same time intense, suppuration takes place. This 
usually commences with pallor, opacity, and swelling of a definite 
patch of liver substance, the tissues immediately surrounding which 
and for some distance beyond are generally more or less deeply con- 
gested. Soon the affected patch becomes softened, and then breaks 
down. The process is identical with that of the formation of abscesses 
elsewhere. Embryonic cells make their appearance in large numbers, 
the hepatic cells become swollen, granular, fatty, and fall into detritus, 
and the web of connective tissue in which these elements are imbedded 
softens and disappears under the influence of the inflammatory exuda- 
tion and growth. If the abscess extend, these processes gradually 
involve the surrounding structures, partly by simple extension, partly 
by the development of new foci in the immediate vicinity ; and it not 
unfrequently happens that under such circumstances abundant shreds 
and filaments of a pinkish gray hue and soft consistence hang from the 
parietes of the abscess into its cavity, and that these if traced outwards 
are found to constitute a pulpy flocculent network, from the meshes of 
which the disintegrated liver-cells have disappeared, but which is 
infiltrated more or less abundantly with pus. The purulent contents 
of hepatic abscesses vary in character, and are not unfrequently tinged 
with bile ; they are very often glairy and of a greenish hue. Hepatic 
abscesses vary in their seat, size, and number. They may be found in 
any part of the liver. They may range from the size of a pin's head 
up to that of a cocoanut, and, indeed, are sometimes much larger than 
this. In the Netley Museum (according to Dr. MacLean) is an 



I 



HEPATITIS. 



717 



hepatic abscess which contained no less than seventeen pints of pus. 
They may be solitary, or may amount numerically to 20, 30, or even 
100. Idiopathic abscesses are for the most part solitary, or occur in 
small numbers. When they are very numerous there is reason to sus- 
pect a pysemic origin. It is important, however, to bear in mind the 
remarkable influence which the various tubes permeating the liver 
exert over the distribution and multiplication of abscesses. Thus we 
know that pus or inflammatory lymph gaining entrance into the portal 
vessels may be conveyed in the form of an embolus until arrested in 
some vessel too small for its further transit ; and that as a result con- 
gestion, followed by softening and suppuration, of the area to which 
the obstructed vessel leads takes place. This condition not unfre- 
quently ensues upon a spreading hepatic abscess ; a branch of the 
portal vein in the substance of the liver becomes involved ; pus enters 
the affected vessel and is thus distributed among its ramifications, 
causing sometimes the formation of scattered abscesses in some particu- 
lar district, sometimes a series of branching abscesses due to the con- 
version of the veins themselves into suppurating channels. The same 
thing may occur in connection with the hepatic vein, some large branch 
of which may become perforated by an advancing abscess, and then, 
communication with the cava having been cut off by the formation of 
a plug, the pus may flow backwards into the tributary branches, and a 
ramifying abscess result. Again, the hepatic ducts may be the seat of 
a like mischance. They may become perforated, and the abscess may 
then discharge itself into the bowel ; or, the duct becoming obstructed, 
below the seat of perforation, the pus may be driven back into the 
smaller branches. Inflammation, commencing in the biliary ducts, 
sometimes leads to abundant suppuration, and occasionally to the 
almost complete destruction of their parietes and the development of 
irregular branching abscesses. Some of the terminations of hepatic 
abscesses have been indicated in the foregoing statement. It remains 
to add that they may discharge themselves in various directions : 
sometimes externally through the abdominal parietes; sometimes 
through the diaphragm into the pericardium, pleura, or lung ; some- 
times into the peritoneum, or into the stomach, duodenum, or colon. 
Sometimes the abscess burrows, and it may then take almost any 
route, either infiltrating the tissue of the great omentum, or running 
downwards in the meso-colon, or behind the peritoneum, and thus 
finding its way into the caecum or rectum, the bladder or the vagina, 
or taking either of the courses which an ordinary psoas abscess is apt 
to take. In some instances the abscess ceases to spread, the tissues 
around become thickened and indurated, and the matter becomes en- 
cysted, and undergoes fatty, or caseous, or calcareous change. 

4. Chronic Inflammation — Cirrhosis. — In chronic inflammation the 
inflammatory process is indicated mainly by the development of em- 
bryonic tissue in the course of the capsule of Glisson, about the 
distribution of the portal capillaries in the peripheral portions of the 
hepatic lobules, and in the intervals between the lobules. This tissue 
is comparatively slow of growth, but tends to encroach more and more 
upon the normal elements of the lobules, while that which is of older 



718 



DISEASES OF THE DIGESTIVE ORGANS. 



date and furthest removed from the advancing margins becomes grad- 
ually converted into connective tissue. In some instances this process 
occurs mainly in the course of the larger branches of the vena portse, 
ducts, and arteries, which become invested in and compressed by the 
abundant formation of dense connective tissue. In other instances it 
manifests itself principally in the course of the smaller branches of 
these vessels, and then tends to map out the liver-tissue into small 
arese from perhaps a quarter to one-third inch in diameter ; which areas 
becoming compressed by the contracting adventitious growth give 
both to the outer and to the sectional surfaces that finely lobulated or 
hobnail character which is indicative of the so-called " drunkard's " 
liver. In other instances, again, the change largely affects the general 
texture of the liver, all the lobules are more or less involved in it, and 
in many situations probably numerous contiguous lobules become 
wholly effaced, and lost in the adventitious growth. In such cases the 
liver is usually more or less enlarged, and irregular upon the surface ; 
it is extremely dense and tough in texture ; and where the disease is 
most advanced the tissues of the organ present a dense, grayish, some- 
what translucent aspect, studded with a greater or less abundance of 
minute, opaque, yellow granules, which are the more or less degener- 
ated, and fatty or jaundiced remnants of the hepatic lobules. In the 
hobnail liver, the compressed hepatic tissue may present its normal 
hue, but not unfrequently it is at the same time fatty and jaundiced 
and has a light yellow tint, which has been likened to that of beeswax, 
whence the hobnail condition of liver has received also the name of 
cirrhosis. This name, however, is usually most applicable to the last 
described form of the disease. 

Symptoms and Progress. — The symptoms which attend congestion 
and inflammation of the liver are exceedingly various and often so 
slight as to elude observation. They include enlargement of the organ, 
which may be detected by inspection, palpation, and percussion ; 
weight, and uneasiness or pain in the hepatic region, which last is often 
increased, and perhaps developed, solely by pressure, or by change 
of position, or by the respiratory acts ; occasional sympathetic pains in 
the right shoulder, and possibly down the right arm; disturbance of 
the digestive organs, indicated by fulness, flatulence, nausea, sickness, 
and loss of appetite ; and slight febrile disturbance. Jaundice not un- 
frequently supervenes, but is rarely intense. It must be added that the 
pain is always most severe when the surface of the liver is involved; 
that it is then of a pricking or cutting character, resembling that of 
ordinary acute peritonitis ; and that it is in this case chiefly that the 
movements of respiration become affected, as in diaphragmatic pleurisy, 
that the sympathetic pain in the shoulder manifests itself, and that a 
dry hacking cough is induced. 

1. Congestion and Simple Inflammation. — The symptoms of conges- 
tion of the liver or of the congestive hepatitis which takes place in the 
course of obstructive cardiac or pulmonary disease are, uniform en- 
largement of the organ, which probably descends an inch or two below 
the lower margin of the right ribs, and encroaches to an abnormal ex- 
tent on the right half of the thoracic cavity ; pain and fulness in the 



HEPATITIS. 



719 



hepatic region, with considerable tenderness on pressure or percussion ; 
pain or tenderness on lying on the right side ; pain also in lying on the 
left side from the tendency of the liver to drag ; and pain on drawing 
a deep breath or coughing. Slight jaundice is very apt to supervene 
and to persist after all other symptoms of hepatic affection, excepting 
enlargement of the organ, have subsided. Hepatic engorgement comes 
on as a rule, late in the progress of cardiac and pulmonary diseases ; 
and although it often subsides under treatment it is very apt to recur, 
and then to become more or less permanent. 

2. Inflammation of the Ducts. — Inflammation of the biliary ducts is 
usually at first associated with more or less marked gastro-in testinal 
catarrh. The symptoms indeed, which include some degree of fever, 
are then almost entirely due to the gastro-in testinal affection; they are 
mainly flatulence, distension, weight and pain in the region of the stom- 
ach, with nausea and vomiting, and for the most part constipation. The 
proof of implication of the hepatic ducts is furnished after the affection 
has lasted for several days, possibly a week or two, by the supervention 
of jaundice and of some degree of tenderness and enlargement of the 
liver. In many cases the symptoms preliminary to jaundice are so 
vague and slightly developed that they escape observation ; and not 
unfrequently they subside shortly after the supervention of jaundice. 
The jaundice itself, however, with constipation and other results of re- 
tention of bile, usually continues for two or three weeks or a little 
longer. Catarrhal inflammation almost always ends in resolution within 
the period above assigned. Sometimes, however, it becomes chronic, 
and may continue for months with the combined symptoms of gastro- 
intestinal irritation and of retention of bile, the patient probably be- 
coming feeble and emaciated. The consequences of permanent stricture, 
or complete impediment to the escape of bile, will be best considered 
under the head of obstructive disease of the hepatic ducts. 

3. Suppuration. — The symptoms of hepatic suppuration are in many 
cases vague and misleading. This is no doubt due in part to the fact 
that hepatic abscess so often supervenes in the course of dysentery or 
pyaemia, affections which by the severity of their proper symptoms tend 
to overshadow those of the hepatic complication. It is not however 
due entirely to this cause ; for idiopathic suppuration, independent of 
dysentery, and the suppuration which complicates hydatid tumors not 
unfrequently (for a time at least) fail of recognition. The local indi- 
cations of abscess are pain and tenderness in the region of the liver, 
tumor in the same situation, displacement of neighboring organs, and 
interference with their functions. Pain and tenderness may be almost 
entirely absent, and when present vary largely in their intensity and 
extent. They are generally most severe when the abscess approaches 
the surface and this latter becomes implicated. The pain in the right 
shoulder, already referred to, is not unfrequent during the progress of 
suppuration. Whether or not there be any obvious enlargement of the 
liver depends partly on the number, partly on the size, and partly on 
the situation of the abscesses. An abscess, even of large dimensions, 
situated at the back of the liver, or deeply imbedded, may easily es- 
cape observation. It may indeed lead to the descent of the anterior 



720 



DISEASES OF THE DIGESTIVE ORGANS. 



edge of the liver, and so induce a belief in the uniform enlargement of 
the organ, which is of course no sufficient indication of the presence of 
an abscess. When, however, the abscess is situated more anteriorly, 
it tends gradually to form a rounded mass, which increases more or less 
rapidly in size, protrudes the parietes, and sooner or later probably 
yields a distinct sense of fluctuation. This protrusion sometimes oc- 
cupies the scrobiculus, and may then involve also more or less of the 
umbilical and hypochondriac regions ; sometimes it takes place princi- 
pally upwards, displacing the lungs and heart. Not un frequently it 
occurs mainly towards the right side of the chest, in which case the 
base of the lung may be displaced upwards considerably above the 
level of the nipple, and the corresponding part of the thoracic walls, 
with more or less of the adjoining hypochondrium may form a smooth 
rounded swelling. It is always important in these cases to determine 
the exact limits of the hepatic mass and of the area of dulness. As 
regards neighboring organs, the diaphragm is not only frequently dis- 
placed, but from the implication of the convex surface of the liver is 
often embarrassed in its action, and respiration becomes thoracic, shal- 
low, and painful, and cough and hiccough arise ; the stomach, again, 
is often displaced, and nausea, vomiting, and other dyspeptic symp- 
toms may consequently ensue. The general symptoms due to hepatic 
abscess are various. The most important probably are those of fever. 
Fever, however, is sometimes wholly absent, and may indeed be absent 
during the entire progress of cases attended with extensive suppu- 
ration. More commonly, however, there is some elevation of tempera- 
ture, either at the commencement of suppuration or some time or other 
during its progress, or at a late stage when the surface of the liver be- 
comes involved, or during the whole course of the case. The tempera- 
ture does not commonly rise above 102° or 103°, presents for the 
most part morning remissions and evening exacerbations, and is some- 
times attended with chills or even severe rigors, which may indeed in 
their severity and periodicity simulate those of ague. The fever, if 
persistent, assumes a hectic character, and is attended with profuse per- 
spiration, especially at night time. Jaundice is by no means a neces- 
sary accompaniment of hepatic abscess. It is occasionally present, 
however, and is then usually slight. The condition of the digestive 
organs varies considerably. Sometimes they are but little affected ; 
sometimes, on the other hand, the tongue may be coated or dry, and 
thirst, nausea, vomiting, diarrhoea, and other indications of gastroin- 
testinal irritation, or catarrh, may be developed. 

Hepatic abscess is always an affection of great danger, and frequently 
proves fatal. In some cases death is due simply to the impairment of 
nutrition and the extreme debility which extensive suppuration entails. 
Sometimes these conditions are associated with the persistence of a 
febrile temperature, or with the retention of effete matter in the blood ; 
and the patient, previous to death, lapses into a typhoid state, with dry 
brown or black tongue, subsultus tendinum, and muttering delirium. 
In a large number of cases, however, complications ensue, dependent 
mainly on the opening of the abscess into, or the extension of inflamma- 
tion to some neighboring organ. The nature of these has been already 



HEPATITIS. 



721 



sufficiently considered under the head of morbid anatomy. For their 
symptoms we must refer to the account of the diseases of the several 
organs which may be thus implicated. When restoration to health 
occurs it may be due either to the abscess becoming encysted and under- 
going degeneration, or to the discharge of its contents through the ab- 
dominal walls, or through the lung, or into the bowel. 

4. Cirrhosis. — The progress of cirrhosis is for the most part very 
insidious. In many cases no symptoms manifest themselves, sufficient 
at all events to attract attention, until the affection is very far advanced • 
in many, the patient suffers only from the usual symptoms of dyspepsia 
or chronic gastric catarrh, symptoms which may equally occur in the 
absence of hepatic disease; in many, he has vague indications of ill- 
health with progressive loss of strength and emaciation, and these 
phenomena may be associated with distinct evidence of similar disease 
going on in the kidneys; in some, no doubt, slight indications of hepatic 
derangement show themselves from time to time, and, in association 
with the habits or history of the patient, reveal to the careful observer 
the momentous changes which are going on within. The cirrhotic 
liver varies in size and form ; it is generally stated to be enlarged in 
the earlier stages of the disease, and certainly, as a rule, it becomes 
diminished in bulk and altered in form in the later periods; but some- 
times it remains persistently considerably larger than natural. As a 
clinical fact, the cirrhotic liver is usually atrophic, and the normal 
hepatic dulness is consequently diminished in area or suppressed; but 
the presence of an enlarged liver by no means forbids the diagnosis of 
cirrhosis. Apart from these variations in the form of the liver, the 
chief indications of cirrhosis are the supervention of abdominal dropsy, 
haemorrhage (often profuse) from the stomach and bowels, and jaundice. 
The most frequent of these consequences of cirrhosis is no doubt ascites, 
but it does not necessarily become developed even in fatal cases ; and 
even when once it has appeared, will sometimes subside under appro- 
priate treatment, and never recur. Haematemesis and melaena are some- 
times the first indications of the presence of hepatic disease, and the first 
attack may prove fatal. When ojie such haemorrhage has occured, it has 
a marked tendency to recur, and is a phenomenon of very fatal augury. 
Jaundice supervenes in a minority of the cases of cirrhosis, and is very 
rarely intense. But besides the symptoms just enumerated, others of 
more or less importance are commonly present. There is usually pro- 
gressive and finally extreme emaciation, with a sallow or earthy cachectic 
aspect. There is generally more or less obvious disturbance of the 
digestive functions; the tongue becomes coated or dryish, and there 
may be thirst, loss of appetite, with sense of flatulent distension, nausea 
and vomiting; the bowels may be constipated or relaxed, and, indeed, 
diarrhoea, which is apt to assume a dysenteric character, is a not unfre- 
quent precursor of death ; piles are of common occurrence ; the urine 
is often scanty and loaded with lithates ; and there is a liability for 
haemorrhage to take place from the various mucous membranes and 
beneath the skin. The tendency of cirrhosis is always to a fatal issue, 
but the duration of the disease is almost impossible to ascertain. It may 
certainly last for many years ; but when once distinctive symptoms have 

46 



722 



DISEASES OF THE DIGESTIVE ORGANS. 



shown themselves, the patient's days are numbered. He may, however, 
even then survive for a year or two. The immediate causes of death 
are very various. The natural termination is by gradual asthenia. 
But the patient is often carried off by the consequences of the ascitic 
accumulation, or by gastro-intestinal haemorrhage, or by profuse alvine 
discharges, or by the supervention of pneumonia or other pulmonary 
complications. Not unfrequently also, as has been previously hinted, 
the hepatic affection is only one of a series of lesions of an allied char- 
acter involving, it may be, heart, lungs, spleen, kidneys, and other 
organs. The symptoms which attend the compression of the liver by 
a dense fibrous investment are identical with those which result from 
cirrhosis. 

Treatment — The treatment of hepatic inflammation must depend 
on the nature and severity of the symptoms by which it is attended. 
Febrifuge or alkaline medicines, and saline purgatives or mild laxatives 
of other kinds, are generally indicated. Food of unstimulating char- 
acter, for the most part farinaceous substances and milk, should be 
administered. And local pains or uneasiness should be counteracted 
by fomentations or cold applications, or by counter-irritants such as 
mustard plasters and the like ; or if there be much feverishness, and 
the local phenomena be at the same time severe, by the use of leeches 
or the cupping-glasses. Amongst drugs which are frequently had 
recourse to in the treatment of these affections (especially when they 
are severe or chronic in character), and which are for the most part 
highly esteemed, are iodide of potassium, chloride of ammonium, tar- 
axacum, and nitro-muriatic acid. During convalescence good diet, 
change of air, and tonics are always valuable. 

As regards the treatment of congestion and simple inflammation, 
there is nothing special to add to the above directions. When the ducts 
are involved in catarrhal inflammation extending from the contiguous 
mucous membrane of the bowel, the above directions may also be 
carried out. But in these cases it is often well to have recourse to those 
medicines which have a special influence over the morbid conditions of 
this surface, and especially to stomachic combinations such as mixtures 
of soda, potash, or bismuth with rhubarb, ginger, and some bitter infu- 
sion. In these cases emetics are also strongly recommended in the early 
stages of the disease, with the object mainly of promoting the flow of 
bile along the obstructed tubes, or of affecting the dislodgment of the 
plugs of mucus which it is assumed may be impacted in them. 

In the earlier stages of hepatic suppuration, nothing probably arises 
to call for special treatment. When, however, the abscess is so far 
developed as to render its presence pretty certain, the question of evac- 
uating its contents arises. It is a moot point whether it should be 
allowed to take its own course, to open when and where it pleases, or 
whether it should be punctured at the earliest possible opportunity. 
Dr. G. Budd is a strong advocate of the former plan. Many however, 
prefer the latter procedure, and we are of their number, The risks, 
indeed, which attend the progress of an abscess are, partly from the 
amount of disorganization it produces in the liver itself, partly from 
the uncertainty as to the route it may take, so serious, that they can 



MORBID GROWTHS IN THE LIVER. 



723 



scarcely be aggravated by operative procedure and they may be largely 
diminished by it. We believe the best plan is to evacuate the contents 
as soon as the opportunity offers, by means of a very fine trocar and 
canula with or without the aid of the aspirator. This operation may 
generally be safely effected even if no adhesions have formed between 
the liver and the abdominal walls. It is well to avoid the admission 
of air, and to employ an evenly and firmly applied bandage afterwards. 
The operation may be repeated from time to time. If the discharge 
become offensive, and adhesions have formed, a free opening should be 
made and maintained ; and the cavity of the abscess should be occa- 
sionally washed out with weak solutions of some antiseptic, such as 
chlorinated soda, nitric acid, carbolic acid, or quinine. During the 
progress of these cases the patient's strength should be supported by 
tonics, stimulants, and good wdiolesome diet. Opiates are always of 
great value. It will probably be necessary at times to treat gastric 
and other complicating disorders. 

As regards cirrhosis, more important than its treatment by medicines 
is the avoidance of those habits of indulgence in alcoholic drinks on 
which it seems, in the vast majority of cases, to depend. And it should 
be borne in mind that it is not so much the occasionally getting drunk 
which is dangerous in this respect, as it is the habit of constant tippling. 
Even if cirrhosis be in progress, the discontinuance of this habit must 
be of real benefit to the patient, inasmuch as that condition which keeps 
the morbid process active then ceases. It is important that this fact 
should not be forgotten, for the victim of cirrhosis for the most part so 
craves for his accustomed stimulant that the physican is apt unwisely 
to indulge him in his cravings. But besides abstinence from alcohol, 
the patient with cirrhosis should attend carefully to hygienic measures ; 
his diet should be light, nutritious, and not too stimulating or too 
abundant; he should keep good hours, be warmly clad, and take 
moderate exercise. Further, he should be put under a course of vege- 
table bitters, with (especially if there be gastro-intestinal catarrh) the 
addition of some stomachic. Or he may take one of the drugs pre- 
viously recommended for cases in which inflammation is assuming a 
chronic character. The bowels should be kept freely open, but violent 
purging should be avoided. When the various late complications or 
results of cirrhosis, such as jaundice, ascites, hsematemesis, and melgena, 
or dysentery, supervene, they will of course require special treatment. 
But for the details of such treatment we must refer to the articles de- 
voted to these several subjects. 



MORBID GROWTHS. 

Tubercle. 

This affection is much more common in the liver, in connection with 
tuberculosis of other organs, than is generally supposed, but has no 
clinical importance whatever. Miliary tubercles are most frequently 



724 



DISEASES OF THE DIGESTIVE ORGANS. 



met with, and are often present in considerable numbers; but owing to 
their close approximation in color and size to the hepatic lobules, are 
apt, excepting they be at the surface, to elude detection. Occasionally 
tubercles of the average size of a pea or bean are observed. These 
always present a central cavity full of broken-down tissue and biliary 
coloring matter, with a capsule of yellowish or grayish tubercular 
growth. 

Syphilis. 

Morbid Anatomy. — Syphilitic disease is chiefly recognized post mor- 
tem by the presence of gummata which have already undergone retro- 
gressive changes. These are opaque, buff-colored, dense, tough masses, 
rounded or irregular in form, and varying from about the size of a pin's 
head to that of a chestnut. They are rarely solitary, and are often 
grouped in clusters of considerable bulk. They are incapable of enu- 
cleation, and are imbedded in dense fibroid or cicatricial tissue, which 
is continuous, on the one hand, with the bodies just described, on the 
other, with the surrounding hepatic texture. They are mostly solid; 
but occasionally, when one is permeated by a duct, this latter is broken 
down into a cavity within it. Wherever these masses with the sur- 
rounding cicatricial tissue are present, the hepatic surface which corres- 
ponds to them is thickened, drawn in, and sometimes very deeply in- 
dented — facts which prove the chronic nature of the affection, and that 
much contraction of tissue has attended its progress. Not unfrequently, 
in cases where many of these tumors are present, we also find dense 
masses of cicatrix-like tissue, which are either free from obvious tumors 
in their interior, or which, in place of them, present merely a few 
opaque or gritty particles. 

The conditions above described are, however, only the last phases of 
a more acute syphilitic affection. The influence of the syphilitic virus 
on the liver is in the first instance to cause interstitial inflammation, 
which in its features almost exactly resembles that constituting the 
early stage of ordinary cirrhosis. It differs, however (according to 
Cornil and Ranvier), in the fact that it invades the whole substance of 
the hepatic lobules instead of being limited to the interlobular spaces. 
This affection may be general throughout the liver, or may be confined 
to certain arese ; and it tends to produce a condition differing little if at 
all from that of ordinary cirrhosis. It is, however, in this inflamma- 
tory overgrowth of connective tissue that, sooner or later, gummata 
make their appearance. These are due to the active proliferation of 
certain of the cell-elements of the newly-formed fibroid growth, which 
increase in number and diminish in size, and collectively form tumors 
which have a close resemblance to granulation tissue or tubercle in the 
early stage. These growths then rapidly degenerate in their central 
parts, while they increase peripherally, so that at an early period they 
present caseous masses surrounded by a thin rim of living cell-growth. 
After awhile they cease to enlarge, and the whole mass undergoes 
caseous degeneration. Gummata may occur in any situation ; they are 
common on the convex surface of the liver, and, as Virchow points 
out, in situations exposed to injury. They are common, also, in the 



MORBID GROWTHS IN THE LIVER. 



725 



neighborhood of the transverse fissure, and may there seriously inter- 
fere with the permeability of the duets and vessels. Although inter- 
stitial hepatitis is a common result of congenital or hereditary syphilis, 
the firm cheesy masses which have been above described are rarely dis- 
covered in that variety of the disease. 

Symptoms. — The symptoms which may be looked for in hepatic 
syphilis are those of cirrhosis in its various stages, especially, therefore, 
ascites, intestinal haemorrhage, and jaundice. But it must be admitted 
that syphilitic disease is, from first to last, often unattended with symp- 
toms, and that it is not unfrequently discovered post mortem in cases 
where its presence during life had never been suspected. When, how- 
ever, the gummatous growths obstruct the vena portae or the hepatic 
duct, the symptoms due to such lesions will necessarily manifest them- 
selves with considerable, and perhaps sudden, intensity. The detection 
of some irregularity of form in the liver may occasionally aid our diag- 
nosis. The chief grounds, however, for suspecting the presence of 
syphilitic disease in this organ would be the association of symptoms of 
hepatic disorder with a history of syphilis and visible indications of its 
presence in a constitutional form. 

Treatment. — In addition to the treatment suitable for cirrhosis and 
its consequences, the use of antisyphilitic remedies is obviously indi- 
cated in the treatment of hepatic syphilis. 

Non-malignant Growths. 

Under this head we may make a brief reference to two varieties of 
morbid formations which have little more than a pathological interest. 
These are cysts of the liver, and cavernous tumors. The latter are 
small, blackish, spongy masses, rarely exceeding the size of a filbert, 
replacing definite portions of hepatic substance, and consisting of irreg- 
ular intercommunicating vascular spaces, separated from one another 
by trabecule of fibrous tissue covered with pavement epithelium. 
Simple cysts may vary from scarcely visible points up to the size of a 
good-sized orange. They are sometimes solitary, and are then apt to 
be situated towards the median part of the anterior edge of the liver. 
Occasionally they are present in enormous numbers, when they display 
all grades of size and varieties of grouping, studding, however, the 
whole extent of the organ. They are generally thin-walled, and give 
evidence in some cases of their enlargement by the coalescence of 
neighboring cysts ; they are lined with pavement epithelium, and gen- 
erally filled with clear serous fluid. The smaller cysts sometimes con- 
tain yellowish or brownish colloidal masses like those found in renal 
cysts. Cysts, however numerous they may be, rarely, if ever, induce 
hepatic symptoms ; it is possible that the presence of one of large size 
in relation with the anterior edge might be detected by manual exami- 
nation ; as a matter of fact, however, they are rarely, if ever, recog- 
nized during life. The most interesting point in connection with them 
is the fact of their comparatively frequent association with cystic de- 
velopments in other organs, more especially in the kidneys and spleen. 
They must not be confounded with hydatid cysts. 



726 



DISEASES OF THE DIGESTIVE ORGANS. 



Malignant Growths. 

Malignant tumors of the liver are usually secondary to similar 
growths originating elsewhere in the body, and especially, perhaps, to 
such as are developed in the other chylo-poietic viscera. Not imfre- 
quently, however, they are primary. No age is quite exempt from 
liability to such disease, yet it rarely occurs before adult age, and is 
most common in persons of middle and advanced life. It has been 
met with in quite young children, and in them is probably always a 
secondary manifestation. The influence of sex is unappreciable. 

Morbid Anatomy. — Malignant disease appears in the liver in two 
forms, either as isolated tumors or as a more or less general infiltration. 
In the former case the tumors vary in size from that of a good-sized 
orange, or even a cocoanut, down to that of minute granules, which 
the naked eye may fail to recognize. Their general form is globular, 
unless the coalescence of neighboring masses, or accidental circum- 
stances, have led to their irregular development. When they involve 
the surface of the liver, those area of disease which are immediately 
subjacent to the capsule, and which are generally circular, assume a 
peculiar cupped appearance, clue to the presence of a more or less 
prominent tumid peripheral ring, circumscribing a central concave de- 
pression. This cupping is very characteristic, and may be frequently 
recognized in tumors not more than a line or two in diameter as readily 
as in such as have attained the bulk of a chestnut or of an orange. 
There is usually more or less well-marked vascularity of the superfi- 
cial aspect of these tumors, and especially of their peripheral portions 
and of the liver-structure immediately surrounding them. The tumors 
grow at their margins, partly by progressively invading the healthy 
tissues bounding them, partly by the formation in their immediate 
neighborhood of new foci of disease, with which they gradually coa- 
lesce. But, while the marginal growth is in progress, the central por- 
tions fall into more or less rapid degeneration. This may be fatty, 
caseous, or even calcareous, or connected with hsemorrhagic extrava- 
sation. Occasionally their central portions undergo liquefaction, and 
become converted into cysts containing a milky or watery fluid. These 
various forms of degeneration do not, as a rule, occur indiscriminately ; 
each one, in fact, to some extent indicates an inherent peculiarity in 
the tumor in which it occurs, and which is shared more or less by all 
the other tumors which are in genetic relation with it. It is to the 
combination of active peripheral growth with central retrogression and 
necrosis that the superficial cupping to which reference has been made 
is mainly referable. 

Malignant tumors may occur in any part of the hepatic substance, 
and they may vary numerically from one or two to an innumerable mul- 
titude. In the former case they are usually primary, and it is here 
that probably the greatest size of growth is attained. In the latter 
case they are generally secondary to growths elsewhere. The diffused 
or infiltrating form of malignant disease is much more rare than that 
which has just been described. In this case we find the liver gener- 
ally, or large portions of it, greatly enlarged, but retaining their nor- 



MORBID GROWTHS IN THE LIVER. 



727 



mal shape, the enlargement being due to the abundant dissemination 
of small adventitious formations, more or less indistinctly defined, from 
the liver-tissue, and tending to run together, so as to give to both the 
outer and sectional surfaces of the affected organ a more or less spotty, 
or reticulate, or uniform character. In some of these cases, indeed, 
the naked eye fails to detect in the enlarged liver any traces of normal 
hepatic tissue. The presence of distinct rounded tumors may be asso- 
ciated with the condition here described. 

Of the several forms of malignant disease which attack the liver, the 
carcinomata are the most common. The form of carcinoma most fre- 
quently met with is, undoubtedly, the encephaloid, of which several 
subvarieties, not, however, calling for description, exist; scirrhus is 
more rare; and still rarer than scirrhus are melanotic cancer and col- 
loid cancer. Most of these appear under the form of isolated scattered 
masses. Sarcomatous malignant growths are comparatively unfrequent. 
Thp most common and interesting of them is the melanotic variety, 
which is usually secondary to similar disease of the choroid coat of the 
eye, or of pigmentary nsevi. In this case the morbid growth is usu- 
ally very widely distributed throughout the organ, the tumors are 
small and tend to coalesce, and the condition above described as "infil- 
trating" is apt to be produced. The liver often becomes enormously 
enlarged, and assumes, from the intermingling of melanotic spots with 
spots of colorless growth, and the remnants of the hepatic texture, an 
appearance which has been aptly likened to that of granite. Melanotic 
masses or tracts of considerable bulk are, however, not uncommon. 
Other forms of sarcoma, spindle-celled sarcoma, for example, and the 
closely related myxoraata, have been discovered in the liver, secondary 
to similar diseases of remote organs. True epithelioma, as involving 
the liver, is scarcely more than a pathological curiosity. The cylindri- 
cal-celled epithelioma, however, or adenoma, secondary, for the most 
part, to gastro-intestinal disease of the same kind, is probably of more 
frequent occurrence. The tumors which it forms are scarcely distin- 
guishable, excepting microscopically, from those of ordinary carcinoma. 
Lastly, that form of growth known as lympho-sarcoma, or lymphade- 
noma, is not very uncommonly developed in the liver. This may form 
distinct tumors, like carcinoma, but it seems specially to affect the cap- 
sule of Glisson and the interlobular tracts ; so that, in some cases, it 
involves the liver by ramifying through it with the portal vessels, in 
some it follows the ordinary distribution of the fibrous growth of cir- 
rhosis, but in either case is apt to grow out here and there into the form 
of manifest tumors. Other forms of malignant disease besides lympha- 
denoma are liable to invade the liver, at the transverse fissure. In 
cases of gastric or of peritoneal cancer, especially, the small omentum 
is very commonly infiltrated with cancerous growth, which thence prop- 
agates itself along the capsule of Glisson, surrounding and compressing, 
or otherwise involving the veins and ducts. Again, the lymphatic glands 
in this situation are frequently involved secondarily to hepatic or other 
neighboring malignant disease, and may then by their enlargement more 
or less seriously implicate the same channels. 

Symptoms and Progress. — The symptoms which attend malignant 



728 



DISEASES OF THE DIGESTIVE ORGANS. 



disease of the liver are in the main identical with those of cirrhosis and 
other structural diseases of the same organ. They comprise altera- 
tions in its form and size, with local pain or uneasiness ; impediment, 
mechanical and other, to the due performance of the hepatic functions ; 
mechanical interference with the functions of neighboring organs, and 
general impairment of nutrition. Increase of size and alteration of 
shape furnish very important indications of the presence of hepatic ma- 
lignant tumors. The increase may be quite uniform, or, as is more 
commonly the case, dependent on the formation of rounded projecting 
lumps, which may sometimes be readily distinguished by the hand. 
Increase of size alone, however, is not so indicative of the morbid con- 
ditions in question as is rapid progressive increase; nor is the mere fact 
of the presence of irregularity from outgrowths so suggestive as the 
progressive enlargement and development of such excrescences, and the 
presence of a certain degree of hardness and resistance which is not 
usually observed in mere cystic formations. It must be borne in mind, 
however, that malignant disease is often present in a liver which is not 
noticeably altered in form or size ; the growths may be few and small, 
or they may occupy the posterior part of the organ, or the liver itself 
may be concealed by the overlapping of distended and adherent bowel, 
or by other conditions. And, further, it must not be forgotten that 
tumors of the stomach, or of the retro-peritoneal glands, and even of 
the abdominal walls, may seem from their position to be of hepatic 
origin. Pain is, no doubt, a frequent attendant on hepatic malignant 
disease. Sometimes it is excruciating, and apt to come on in parox- 
ysms. It is, however, often absent, and may be totally absent from 
first to last. Jaundice, usually due to obstruction of some of the hepatic 
ducts, makes its appearance sooner or later in a considerable number 
of cases. It is rarely intense, unless the main duct be involved. And 
hence it is mainly in those cases in which malignant disease attacks the 
lesser omentum, and extends thence into the transverse fissure that deep 
jaundice becomes developed. Jaundice is, however, no necessary re- 
sult, and is not unfrequently absent from the most extreme cases — cases 
in which the whole hepatic texture seems to be replaced by the abnor- 
mal growth. Ascites is, perhaps, even more rarely than jaundice a 
direct consequence of malignant disease of the liver. It is often, no 
doubt, developed during the progress of the case, and may be due, as 
in cirrhosis, to impediment to the flow of blood through the portal 
vessels ; but is usually comparatively small in amount, and dependent 
either on peritoneal inflammation or on other abdominal complications. 
When, however, the portal vein is distinctly obstructed, the consequent 
ascites may be considerable, and other consequences of portal obstruc- 
tion, such as melsena, may ensue. In most cases ascites is absent. As 
regards neighboring organs, the pressure of the enlarged and possibly 
painful liver is apt to induce functional disturbance of the stomach on 
the one hand, and pain and difficulty of breathing, and perhaps cough, 
on the other. General impairment of nutrition, debility, and emacia- 
tion are usually marked phenomena of the progress of the disease. It 
may be added that it has been commonly observed that malignant dis- 



MORBID GROWTHS IN THE LIVER. 



729 



ease of the liver is attended with scanty secretion of urine, in which an 
abundant deposit of vermilion or carmine-colored urates takes place. 

In the great majority of cases, malignant disease of the liver is asso- 
ciated with malignant disease of other organs, and the symptoms which 
the patient presents are, therefore, of complicated origin. This fact, 
while it may be of the greatest value in enabling us to form a correct 
diagnosis with regard to the nature of the malady under which he is 
laboring, often renders it difficult to determine how much and which 
of his sufferings are due to the hepatic disease. As of malignant dis- 
ease generally, so no doubt of that affecting the liver only, it may be 
regarded as a general rule that the symptoms are insidious and pro- 
gressive; that the disease has usually made more or less considerable 
progress before the suspicion arises that the patient is ill ; that this 
suspicion is first aroused in some cases by the gradual creeping on of 
emaciation, debility, and cachexia, in some by the slow supervention 
of gastric symptoms, in some by a sense of fulness, or heat or pain, con- 
tinuous or paroxysmal, in the hepatic region, in some by the develop- 
ment of obvious tumors. During the further progress of the case all 
the symptoms of this period of invasion are apt to become commingled, 
and those other special phenomena which we have attributed to the 
disease to supervene. It must not, however, be forgotten that malig- 
nant disease of the liver may prove fatal without having ever been 
attended with some of those symptoms which would seem to be most 
typical of it; not only, as we have pointed out, may there never be 
obvious tumor, or hepatic pain, or jaundice, or ascites, or distinct impair- 
ment of the digestive functions, but the so-called "cancerous cachexia'' 
may never be distinguishable, and the patient, instead of becoming 
emaciated, may remain in good flesh, or even become fat. 

From the difficulty of determining the date at which it commences, 
it is impossible to determine, even approximately, the duration of 
hepatic malignant disease. Nor is it important to do so. It is sufficient 
for practical purposes to know that when once the disease has given 
clear evidence of its presence, the patient rarely survives beyond twelve 
months, and that much more frequently his death occurs within six or 
eight months. The natural cause of death is gradually increasing 
asthenia; but the fatal event is apt to be accelerated by the occurrence 
of peritonitis or other complications. 

Treatment. — Medical skill is powerless to arrest the progress of the 
morbid growths under consideration. All that the physician can do is 
to relieve pain and uneasiness by opium or other sedatives, or by local 
measures; to check vomiting, to obviate constipation, and generally to 
aim at relieving the various symptoms which distress the patient; and 
by hygienic and other measures to maintain, as far as possible, his 
general health and strength. 



730 



DISEASES OF THE DIGESTIVE ORGANS. 



PARASITIC AFFECTIONS OF THE LIVER. 

Hydatids. 

Morbid Anatomy. — These parasites affect the liver more frequently 
than any other organ; they are, however, not uncommonly developed 
in various parts of the subperitoneal connective tissue, more especially 
that of the pelvis. In the liver they are usually solitary; but some- 
times two or three hydatid tumors are simultaneously developed there; 
and sometimes also hydatid tumors in the liver are associated with 
other, occasionally numerous, similar tumors in various parts of the 
abdominal cavity. Their size varies; they are not unfrequently met 
with as large as a child's head, and containing several pints of fluid. 
They are slow however in attaining these dimensions; and although 
the exact period during which they live and grow is uncertain, there is 
no doubt that it occasionally extends to at least ten or fifteen years, 
possibly even to twenty or thirty. They are for the most part globu- 
lar in form, unless bands or ligatures, or other accidental conditions, 
have interfered with their development. In the liver they most fre- 
quently infest the right lobe, a fact which is probably due simply to its 
comparatively large size. They appear to originate in the hepatic sub- 
stance, which becomes displaced by them in the course of their devel- 
opment, and at the same time the seat of fibroid growth and induration 
in the layer which immediately surrounds them. By this means a kind 
of fibrous capsule is formed. In most cases there is no communication 
between the hydatid tumor and the hepatic ducts; in some cases, how- 
ever, a large, and even a primary duct may be found, leading directly 
into the cavity, and the open continuation of this duct and of some of 
its branches, studded with the orifices of their numerous smaller tribu- 
taries, may probably be seen ramifying upon its walls. The normal 
event of hydatid tumors, and one which is fortunately far from uncom- 
mon, is the death of the parasite, and the degeneration and contraction 
of the tumor. This has already been sufficiently described; it may, 
however, be added that hsernatoidin crystals derived from the biliary 
coloring-matter, are not unfrequently met with in such degenerated 
cysts. Other events of not uncommon occurrence are the rupture of 
the cyst by accidental violence and its suppuration. 

Symptoms and Progress. — Hydatid tumors are rarely attended with 
pain, or even uneasiness, except by reason of their bulk or in conse- 
quence of the supervention of inflammation, or of the pressure which 
they exert on neighboring parts. It generally happens, indeed, that 
the patient's attention or that of friends is first attracted by the discov- 
ery of gradual and at the same time more or less unsymmetrical abdom- 
inal swelling. So that when the case first comes under medical 
observation there is generally an obvious tumor in some part of the 
abdomen, and the question is consequently not so much whether or not 
a tumor is present, as what the nature of the existing tumor is. 

Uninflamed hydatid tumors which abut upon the surface, usually 
appear as rounded, tense, elastic swellings, free from pain or tenderness. 



PARASITIC AFFECTIONS OF THE LIVER. 



731 



They often fluctuate distinctly, and are not unfrequently attended with 
the peculiar hydatid thrill first described by Briancon and Piorry. 
This, which is best recognized by placing the left hand flat and closely 
applied upon the tumor, and then percussing sharply with the fingers 
of the right hand, consists in a peculiarly long-sustained tremor, re- 
minding one of that experienced on an iron railway bridge during the 
passage of a train over it. The nature of the swelling may how- 
ever generally be placed beyond the possibility of doubt by tapping. 
The fluid which comes away from the living hydatid cyst is trans- 
parent and colorless, like water, limpid, containing an excessive quan- 
tity of chloride of sodium, and as a rule neither albumen nor fibrino- 
gen. Its specific gravity varies from about 1008 to 1013, and its 
reaction is either neutral or slightly alkaline. Further, it may con- 
tain echinococci or microscopic hydatids. The position of the tumor 
will necessarily vary with its seat of development. If in the liver, it 
perhaps most commonly projects forwards, occupying the scrobiculus, 
or this, and more or less of the other abdominal regions which adjoin 
it; it may, however, protrude directly upwards, pushing the heart be- 
fore it upwards and to the left ; or it may displace the right half of 
the diaphragm, together with the base of the lung, at the same time 
distending the lowermost zone of the right side of the chest ; or again 
it may be developed in the posterior region of the liver, and so to a 
great extent elude observation. It would be impossible to lay down 
any rules with regard to the situation of the tumor when it originates 
in other parts of the abdominal cavity. Suffice it to say that it may, 
according to circumstances, assume the position of a renal, omental, 
ovarian, uterine, aneurismal, or other growth ; and that it is with these 
mainly (especially if they be cystic) and with hepatic swellings, more 
especially abscesses and dilated gall-bladders, that hydatid tumors may 
be confounded. When displacing the right lung upwards, and distend- 
ing the corresponding part of the chest, they frequently simulate pleu- 
ritic effusion. 

It must be borne in mind that the rules above laid down are none 
of them of quite universal application. An hydatid cyst may be sepa- 
rated from the surface by a considerable thickness of the tissue in which 
it originates, or by an exceedingly thick and dense capsule, under which 
circumstances it may not improbably be mistaken for a solid tumor. 
Or owing to various accidental circumstances, or to the simultaneous 
development of several cysts, the tumor may appear nodulated or mul- 
tiple, and may present different degrees of consistence and of elasticity 
at different points, when it may readily be taken for a lobulated malig- 
nant growth, or for a compound ovarian or other cystic formation. The 
diagnosis of a contracted and degenerated cyst, even if occupying a 
situation accessible to examination, would, without the guidance of a 
clear history, be exceedingly difficult, if not impossible. 

Hydatid tumors are not always unattended with symptoms ; they 
may, from their bulk or situation, interfere seriously with respiration ; 
they may cause vomiting and other dyspeptic phenomena ; they may 
compress the hepatic ducts and so induce jaundice, or the portal vein 
causing ascites, or the inferior cava leading to anasarca of the lower 



732 



DISEASES OF THE DIGESTIVE ORGANS. 



extremities and probably congestion of the kidneys ; and hence by the 
gradual supervention of asthenia or of asphyxia, or of other conditions, 
death may after awhile ensue. The sudden rupture of hydatid tumors, 
with the escape of their contents into the peritoneal cavity, is usually 
followed by rapidly fatal peritonitis. The symptoms due to suppura- 
tion are sometimes obscure, sometimes very well-marked ; they are, 
however, those which usually attend extensive suppurative inflamma- 
tion. The hydatid cyst becomes in fact converted into an abscess, and 
comports itself in its further progress exactly as any other large hepatic 
abscess. It increases more or less rapidly in size, and after awhile dis- 
charges its contents either at the external abdominal surface, or into 
the pleura or through the lung, or into the pericardium, or into the 
stomach or intestine, or into the abdominal cavity, or into the hepatic 
ducts and thence into the duodenum. Other rare terminations have 
been met with, such as by perforation of the vena cava, or of the right 
auricle of the heart. The proof that an hepatic or abdominal abscess 
is of hydatid origin, rests on the discovery of either hydatid mem- 
branes or echinococci, or their debris in the pus which escapes. The 
hooklets, which are peculiarly indestructible, should especially be 
looked for. 

Treatment. — ~No medicinal treatment avails either to cause the death 
of hydatids or to arrest their growth. For the cure of the disease we 
must look to local measures only. And these consist mainly in the 
evacuation of the contents of the cysts. The puncture of the cyst 
with a bistoury, or a trocar and canula sufficiently large to admit of 
the escape of the cystic progeny of the parent hydatid, is a procedure 
which has been largely adopted. It is obvious, however, that it can 
only be adopted with safety when the cyst is adherent to the abdominal 
parietes, and the escape of the contents into the peritoneal cavity thus 
prevented. It can only, therefore, be justifiably had recourse to when the 
cyst has undergone inflammation or suppuration and has consequently 
become united with the surface over it ; or after measures have been 
taken to insure the formation of adhesions. Among the methods 
which may be adopted to effect this object are : first, incision through 
the abdominal parietes until the cyst is exposed : second, the gradual 
destruction by caustics of a limited area of the abdominal walls down 
to the parietal peritoneum over the intended seat of puncture ; and, 
third, Trousseau's method of multiple acupuncture. In all such cases 
it is essential that the patient should be kept at rest, and the abdominal 
walls in close apposition with the subjacent cyst-walls, by means of 
pressure, in order to insure the formation of adhesions and their main- 
tenance when formed. 

A far better plan, however, for evacuating the contents in all those 
cases in which suppuration has not yet occurred, is that which was 
strongly recommended some years since by Moissenet, and has since 
been successfully employed in this country, and especially in the Mid- 
dlesex Hospital by Drs. Greenhow and Murchison. It consists in the 
employment of an exceedingly fine trocar and canula and the removal 
of more or less of the fluid contents only of the cyst. The minute 
puncture made by this instrument rarely permits, even if no adhesions 



PARASITIC AFFECTIONS OF THE LIVER. 



733 



be present, of the escape of any appreciable quantity of the hydatid 
fluid into the peritoneal cavity, and is rarely, therefore, followed by 
grave peritoneal complications. In order, however, to guard against such 
accidents it is well to select some prominent and central portion of the 
hydatid protuberance for puncture, to refrain from removing the whole 
of the contents at one operation, and after the operation to keep the 
patient at perfect rest and the punctured parts in close apposition by 
means of a compress and bandage. It is further desirable to preclude 
the entrance of atmospheric air, and for this reason also, if the aspirator 
be not employed, to be content with the partial evacuation of the cyst. 
This treatment will probably have to be repeated two or three times 
before the tendency of the cyst to refill ceases ; but usually before long 
the parasites perish, and then the tumor slowly shrinks. Another 
method of treatment has been recommended by Dr. Althaus, and suc- 
cessfully practiced by Dr. Fogge and Mr. Durham. The details are 
furnished by Dr. Fagge in the following words : " Two electrolytic 
needles are passed into the tumor one or two inches apart, they are 
then attached to two metallic wires, both connected with the negative 
pole of a battery of ten cells. A moistened sponge forms the termina- 
tion of the positive pole, and is placed on the patient's skin at a little 
distance from the point of entrance of the needles. Its position is 
changed from time to time during the operation. The current is 
allowed to pass for about ten minutes. At the end of this time the 
needles are gently withdrawn and the seats of puncture covered with 
adhesive plaster." The above operation is often attended with some 
escape of fluid into the abdominal cavity, and some rise of temperature 
with other febrile symptoms. And as with simple paracentesis, so 
here, the immediate effects are not always obvious, and the operation 
may need to be repeated. It has been recommended by some that 
after the evacuation of more or less of the contents of the cyst, a solu- 
tion of iodine, or of perchloride of iron, or of bile or some other anti- 
septic or parasiticidal fluid should be injected ; and this practice has 
been in some cases successful. It is obvious, however, that the injec- 
tion of irritating fluids is apt to induce inflammation and suppuration, 
which are in themselves very undesirable ; and it is at least doubtful 
whether the death of the parasite is more surely attained by this pro- 
cedure than it is by the simple evacuation of the fluid contents. If 
peritoneal inflammation unfortunately ensue, it must be combated by 
appropriate treatment. If suppuration of the cyst take place (and this 
is an accident for which we must be prepared), it will also be necessary 
to accommodate our treatment to the altered condition of things. But 
especially the local treatment will need some modification. It will 
then at all events be desirable, so soon as we are satisfied that the cyst 
is adherent, that a free opening be made, and the contents, inclusive of 
the hydatid cysts, freely evacuated. Whether, however, that opening, 
should be made with the trocar and canula, or with the knife, or 
whether the opening should be allowed to close or be kept open, and 
in this latter case whether the contents should be allowed to escape by 
means of a drainage-tube or not, or whether the cavity should be 
washed out with some disinfectant solution, are points on which it is 



734 



DISEASES OF THE DIGESTIVE ORGANS. 



difficult to express oneself absolutely. The exigencies of cases as they 
arise necessarily call for modifications in the details of treatment. It 
is needless to discuss the treatment of the numerous other accidents and 
complications which are apt to manifest themselves during the course 
of hydatid disease. 



FATTY LIVER. 

Causation. — The deposition of fat-globules in the hepatic cells is not 
in itself an indication of disease. It is frequently observed to a small 
extent in a state of health ; and sometimes indeed to a large extent 
in healthy persons who lead sedentary lives, or feed largely, and 
especially in those whose diet comprises an excess of fatty matter, 
or who have a tendency to obesity. The abundant deposition of fat, 
however, which constitutes what is meant by the fatty liver, is more 
frequently associated with various morbid states either of the system 
or of the liver itself. Among the former of these we may enumerate 
chronic alcoholism, heart disease, malignant disease, and especially 
pulmonary phthisis ; among the latter cirrhosis, lardaceous degenera- 
tion, and the indurated condition which supervenes on chronic cardiac 
or pulmonary affections. 

Morbid Anatomy. — In the early stage of fatty deposition fat-globules 
of small size are found scattered in the substance of the hepatic cells ; 
at a later period many of the globules have enlarged, partly by coales- 
cence, partly by fresh deposition, and may then considerably exceed in 
size the nuclei around which they cluster; at a still later period com- 
plete coalescence takes place, and the cells distended with their oily 
contents assume very much the appearance of the cells of adipose 
tissue. The deposition of fat always commences at the periphery of 
the hepatic lobules, and is very often limited to the periphery; and 
even when the change becomes universal, as it occasionally does, it is 
still this outer zone which chiefly suffers. The presence of fat in any 
abundance renders the affected portion of the liver swollen, soft, dull, 
and opaque, the yellowness due to bile and the redness due to blood 
alike disappearing in a greater or less degree. Further, the tissues 
often become distinctly greasy, their fat adhering to the knife and 
fingers. It often happens that in cirrhosis the isolated nodules of 
hepatic substance are more or less .loaded with oil. In lardaceous 
change scattered patches of hepatic tissue are by no means unfrequently 
similarly affected. In cardiac and chronic lung disease the deposition 
is mostly limited to the peripheral parts of lobules, and it is indeed 
owing mainly to the contrast between the outer fatty and ansemic zones 
and the central deeply congested arese, that the term "nutmeg" has 
been applied to this form of hepatic affection. It is not uncommon to 
find the fatty and congested regions of the lobules separated from one 
another by a line of deep jaundice. In the fatty liver of phthisis and 
other wasting diseases, the fatty accumulation may still be mainly 
peripheral, and the liver may consequently present something of the 



LARDACEOUS LIVER. 



735 



nutmeg character ; but not unfrequently the organ is pretty generally 
involved. Under these circumstances it presents a nearly uniform 
pallor, dulness of aspect and softness, and its bulk is generally very 
largely increased. The enlargement due to fatty deposition is as 
nearly as possible uniform. The fat consists mainly of olein and mar- 
garin, with traces of cholesterin. Its amount varies; in extreme 
cases from 43 to 45 per cent, of the hepatic substance has been found 
to consist of fat, and indeed after removal of the water Frerichs has 
found no less than 78 per cent, of the residue to consist of fat. 

Symptoms. — It is natural to believe that excessive accumulation of 
fat in the liver might aifect very seriously the functions of that organ ; 
and many different symptoms have been ascribed to it. We are bound, 
however, to confess that we have never met with a case in which he- 
patic or other derangement has been clearly attributable to it. And, 
indeed, it must not be forgotten that fatty accumulation is not un- 
frequently associated with structural changes in the liver; and that 
where hepatic symptoms have been associated with fatty liver, they 
have been probably clue to these associated lesions. The enlargement 
due to fatty deposition in the liver may often be recognized during life, 
and occasionally the augmented bulk of the organ may produce ful- 
ness, weight, and uneasiness in the side. 

Treatment — When fatty liver depends on actual disease, it is essen- 
tially by treating the disease that we must hope to remove the hepatic 
accumulation. When we have reason to believe that enlargement of 
the liver, in persons who are fairly healthy, is due to fatty deposit, our 
treatment must be guided by our knowledge of their habits and ten- 
dencies, and must necessarily be mainly hygienic. It is, however, very 
seldom that we shall be called upon to make fatty liver a distinct ob- 
ject of medical treatment. 



LARDACEOUS LIVER. 

Causation. — This affection is secondary to those morbid conditions 
of the system in which lardaceous disease generally takes its origin : 
principally chronic phthisis, tertiary syphilis, caries of bone, and other 
conditions attended with prolonged suppuration. 

Morbid Anatomy. — The lardaceous change takes place first, accord- 
ing to Rindfleisch, in what he terms the arterial zone of the hepatic 
lobules, that is, midway between the centre and the periphery, and 
commences both in the walls of the minute arteries and capillaries of 
the part, and in the hepatic cells. But soon the morbid process ex- 
tends to the central portions of the lobules, and after a time the 
periphery becomes equally involved. The change is attended with 
great thickening of the affected vessels, and the acquisition by them of 
a peculiar homogeneous pellucid character ; and with considerable en- 
largement of the hepatic cells, which lose all trace of granules, of bile- 
pigment and of nucleus, and become irregular or botryoidal vitreous- 
looking lumps, which after awhile break down into irregular fragments. 



736 



DISEASES OF THE DIGESTIVE ORGANS. 



The lardaceous liver, like the fatty, undergoes uniform enlargement in 
all its dimensions. It becomes smooth, heavy, and of somewhat 
doughy consistence ; and if uniformly affected, presents a remarkably 
homogeneous sectional surface, of a grayish tint, with a peculiar 
glistening, or rather, perhaps, semi-translucent aspect, which has some 
resemblance to that of beeswax. It is equally free from biliary and 
vascular congestion, and from moisture. The lardaceous change is not 
unfrequently associated with more or less fatty deposit, sometimes with 
cirrhosis, sometimes with syphilitic disease. 

The size which the lardaceous liver may attain is almost unlimited. 
It has been met with of weights ranging between ten and fifteen 
pounds. This increase of size is, however, a very slow process, and 
often extends over some years. 

Symptoms. — The circumstances which in combination justify the 
diagnosis of this affection are the slow but continuous uniform en- 
largement of the liver, without pain or obvious hepatic symptoms ; the 
long continuance of some one of those morbid conditions which we 
know to be conducive to lardaceous degeneration ; and the coetaneous 
enlargement of the spleen, and involvement of the kidneys. There is 
no doubt that patients with lardaceous liver manifest, as a rule, 
marked cachectic symptoms ; but there is little evidence to show that 
these are dependent in any peculiar degree upon the hepatic disease. 
It is true that a slight icteroid tinge occasionally manifests itself after 
awhile, and that the bile in the gall-bladder and ducts is usually pale 
and watery ; but, on the other hand, there is never obvious pain in the 
region of the liver, never deep jaundice, rarely if ever ascites, and (be- 
yond the occasional presence of bile-pigment in the urine) nothing in 
that secretion distinctly to indicate impairment of hepatic function. 
The greater number of cases in which lardaceous disease manifests itself 
no doubt end fatally ; but there is reason to believe with Frerichs that, 
if the change be not far advanced, the arrest of the morbid process upon 
which it is dependent may be followed by the restoration of the lar- 
daceous organs to the condition of health. 

The treatment of lardaceous change merges in the treatment of the 
disease which produces it. 



GALLSTONES. 

Very little of practical importance is as yet known with respect to 
the variations in quantity and quality of the bile, and the influence of 
these variations on the action of the bowels, the assimilation of alimen- 
tary matters, and the general health. We know, no doubt, that when 
the bile which enters the bowels is deficient in quantity, fatty matters 
are imperfectly assimilated, the evacuations are fetid, and the bowels 
usually constipated ; and we have reason to believe that when there is 
an excessive discharge of bile, bilious diarrhoea and vomiting may be 
excited; but, on the other hand, we know that in many diseases, 
whether of the liver itself or of the general organism, the bile is found 



GALLSTONES. 



737 



post mortem deviating widely from its normal condition, and yet there 
have been no symptoms during life which could be distinctly referred 
to this deviation. There is, however, one abnormal condition of the 
bile, of great practical interest, which reveals itself to us, not directly 
by any of those consequences which have been enumerated, but by the 
formation of concretions which bring with them special symptoms and 
special dangers. 

Causation. — The origin of these bodies is obscure. It is easy, of 
course, to understand their increase of size by the accretion of addi- 
tional solid matter, but it is not generally easy to determine the cause 
of the first step in their development, namely, the formation of a nu- 
cleus. In some rare cases this latter body has been found to be a frag- 
ment of a needle, or a dead entozoon, or a small blood-clot, or (accord- 
ing to Dr. Thudichum) portions of the epithelial lining of the gall-ducts. 
In the majority of cases, however, it consists of a mass of concreted 
biliary coloring matter. Concentration and stagnation of bile have 
doubtless some influence over the production of gallstones, as is shown 
by their much more frequent formation in the gall-bladder than in the 
hepatic ducts, and probably also by their comparative frequency in 
cases of carcinoma, and other organic diseases of the liver. It is not 
clear that the tendency to biliary calculi is inherited, or that it is ever 
traceable to any dyscrasia, notwithstanding the statements which are 
made to the effect that it is generally associated with gout, renal calculi, 
or other maladies. On the other hand, we know that gallstones occur 
much more frequently in women than in men, and rarely, in either 
sex, below the age of thirty. They have, however, been met with at 
earlier periods of life, and even in infancy. There is reason also to 
believe that they specially affect those whose mode of life is sedentary. 
The influence of diet is unknown. 

Morbid Anatomy. — Gallstones vary in size from mere granules up 
to masses moulded to the form of the gall-bladder, measuring three or 
four inches in length, and from one to one and a half in thickness, and 
weighing between one and two ounces. When they are minute, less 
in size than (say) a poppy seed, they are usually spoken of as biliary 
sand. Gallstone may be solitary, but they are much more frequently 
multiple; many have been found at one time scattered throughout the 
biliary ducts, and several hundreds in the gall-bladder. When occu- 
pying the latter cavity their size has necessarily some relation with 
their number ; at all events, when they are very numerous, they can- 
not possibly be large, whereas solitary calculi, and calculi occurring in 
groups of two or three, often attain considerable dimensions. The 
forms which they assume depend mainly on their relations, during 
their growth, with the surrounding parts. In the commencement 
they may be rounded or amorphous accumulations of biliary coloring 
matter, or in rare cases rhomboidal tablets of cholesterin. But with 
their increase of size some modification takes place. They may acquire 
a branched or coral-like form in the smaller bile-ducts ; in the larger 
ducts or in the gall-bladder they may form roundish masses, or, if still 
growing, may accommodate their general shape to that of the cavity 
which contains them, but in the gall-bladder, when the simultaneous 

47 



738 



DISEASES OP THE DIGESTIVE ORGANS. 



development of many gallstones takes place, they mutually interfere 
with each other's growth, and instead of assuming a globular form, 
become polyhedral or faceted or flattened one against the other. In 
this manner the gall-bladder may become uniformly distended with a 
pyriform mass of closely-packed, mutually -fitting gallstones ; and, in- 
deed, it generally happens that when this cavity appears to be occupied 
by a single large calculus, this consists of at least two or three, and 
generally of a larger number, of well-articulated but distinct masses. 

The surfaces of gallstones are commonly smooth, but sometimes 
granular or tuberculated, and in color may vary from almost milk- 
white, through yellow or brown, to deep reddish or greenish black. 
Their specific gravity ranges between .8 and 1.5; they are generally, 
however, heavier than water, and sink in it. In some cases they are 
so soft and friable as readily to fall to powder between the finger and 
thumb • and generally they are sufficiently soft to admit of being 
readily crushed into irregular fragments, or of being cut with a knife. 
They are usually soapy or greasy to the touch. As to their general 
structure, they sometimes consist of a simple tuberculated accumulation 
of pigmentary matter, sometimes of a nearly homogeneous waxy mass. 
In the majority of cases, however, three regions may be more or less 
obviously recognized ; a central nucleus, which, as has been already 
stated, is mostly pigmentary and often irregular in form and shrunken ; 
a zone of various thickness around this, which is usually somewhat 
homogeneous in texture, but marked more or less obviously with 
radial lines; and a cortical lamina, also of various thickness, which 
is usually concentrically striated. These several regions are further 
characterized by differences of color. 

The chief constituent of gallstones is cholesterin, and this forms 
on the average from 70 to 80 per cent, of the entire mass ; but in addi- 
tion to this are found in various proportions biliary coloring matter, 
biliary acids, and lime. Other ingredients are so rare or so small in 
quantity as scarcely, from a clinical point of view, to be worth con- 
sideration. They are chiefly the fatty acids, uric acid, earthy phos- 
phates, alkaline salts, and mucus. Calculi consist sometimes almost 
entirely of pigmentary matter, sometimes almost entirely of carbonate 
of lime with some admixture of phosphate, and sometimes of pure 
cholesterin. Moreover, the different laminae often differ in composi- 
tion, the outer shell of large calculi frequently presenting an excess of 
earthy salts. 

The consequences of biliary calculi are very various. In many 
cases they form in the gall-bladder, and slowly grow r there until, 
moulded to its shape, they entirely fill it. The gall-bladder contracts 
upon them, ceases to perform its proper functions, and forms merely 
the capsule of what then probably proves to be an inert mass. Some- 
times the presence of these bodies irritates the mucous membrane of 
the bladder into inflammation, and it may be into suppuration and 
ulceration. Slight attacks of inflammation doubtless arise occasionally 
and subside again wdthout further result. But when the inflammation 
is of a more intense character, the cavity of the bladder may be con- 
verted into an abscess which either discharges itself per vias natwales, 



GALLSTONES. 



739 



or opens externally, or into the stomach or some other viscus, or into 
the peritoneum ; or the mucous surface of the bladder may at some 
point or other be fretted by its contained calculi into an ulcer which, 
gradually eating its way through the parietes, then probably glued to 
some neighboring part, forms a sinus or diverticulum which, like the 
abscess, may open in one of several directions. The most common 
routes are externally through the abdominal walls, and into the duo- 
denum, and the transverse colon. In many cases a gallstone becomes 
dislodged, and slips into the cystic duct, whence it may pass slowly 
onwards until it reaches the duodenum. The duration of this process 
is very various ; in some cases it may be over in a few hours, more 
frequently it occupies several days. The stone generally travels by 
fits and starts, and may be either temporarily or permanently arrested 
in any part of the channel along which it passes. If arrested in the 
cystic duct, it probably leads to its complete closure and to the enforced 
disuse of the gall-bladder, which may either shrivel away or become 
dilated into a mucous or serous cyst ; if arrested in the common duct, 
it probably sooner or later obstructs the flow of bile, and this fluid 
then accumulates in the gall-bladder and in the ducts ramifying in 
the liver, which become distended ; but again, in either of these situa- 
tions the presence of the stone may fret the surface against which it 
lies, and cause its ulceration and possibly perforation, and thus lead to 
the formation of a local abscess, or to general peritonitis, or to some 
abnormal communication with the duodenum, colon, or the portal vein. 
When once a gallstone has descended from the gall-bladder, other 
stones, if they exist, are apt to follow ; and moreover, their passage is 
generally more readily and speedily effected than that of their pioneer. 

Symptoms and Progress. — The presence of gallstones in the bladder 
or hepatic ducts does not necessarily cause symptoms, and in a large 
number of cases is from first to last unattended with symptoms. Gall- 
stones may, however, occasionally be recognized, owing to the detection 
on manual examination of an irregular hardish crepitating lump in the 
situation of the gall-bladder. When their presence excites inflamma- 
tion, we may look for some tenderness, pain, and fulness in the same 
situation, with more or less obvious febrile disturbance. But unless 
any more distinctive phenomena arise, the exact nature of the affection 
can scarcely be positively diagnosed. Such phenomena are: the for- 
mation of an abscess superficial to the bladder in the abdominal parietes, 
and the ultimate escape of gallstones with the other contents of the 
abscess ; and the discharge of gallstones through an ulcerated opening 
into the duodenum or colon, and their escape with the faeces, or their 
arrest in the small intestine, followed by enteritic symptoms. It must 
not be . forgotten, however, that each of these phenomena may arise 
without having been preceded by any clear symptoms of inflammation 
of the gall-bladder. The symptoms most characteristic of the presence 
of gallstones are those which depend on the dislodgment of these 
bodies and their subsequent passage along the cystic and common 
ducts. They resemble in many important respects those due to the 
transit of a renal calculus along the ureter. They are : pain more or 
less severe, coming on suddenly and lasting, with irregular intermis- 



740 



DISEASES OF THE DIGESTIVE ORGANS. 



sions and exacerbations, for a few hours or for several days ; faintness, 
nausea, and vomiting; and the consequences of impediment to the 
escape of bile into the intestines. The pain (frequently termed hepatic 
colic) varies in its intensity, situation, and quality. Sometimes it is 
comparatively slight, sometimes so severe that the patient writhes and 
cries out in his agony; its character is aching, cutting, tearing, or 
burning, and generally it is attended with or specially characterized 
by an unbearable sense of tightness, constriction, or cramp; it is 
usually referred to the pit of the stomach or to the umbilicus, whence 
it extends to the back between the shoulders, to the chest or to the 
shoulder-tip, or down into the lower part of the abdomen. It may 
even from its situation simulate the passage of a stone along the ureter. 
There is not usually any material tenderness, and pressure, indeed, may 
afford some relief to the pain. Hepatic colic is said to be further char- 
acterized by often coming on suddenly two or three hours after a meal, 
at the time when the passage of food along the duodenum excites the 
flow of bile from the gall-bladder and biliary passages. It often comes 
to a sudden end in consequence either of the slipping back of the stone 
into the gall-bladder, its arrest at some point in the course of the cystic 
or common duct, or its escape into the bowel. The faintness, nausea, 
and vomiting are not in necessary relation with the severity of the pain ; 
the patient may be simply chilly, or he may have severe rigors; his 
surface may become cold and pale, and bathed in profuse perspiration, 
his pulse rapid and small ; he may complain simply of nausea, or suffer 
from severe vomiting. The sense of faintness may amount to an actual 
attack of syncope; and the syncopic attack has proved fatal. A gall- 
stone may pass on from the bladder to the duodenum with all the above 
symptoms, and yet cause no material stoppage of bile ; in a large num- 
ber of cases, however, its presence in the common duct is followed by 
more or less complete retention, which reveals itself by the vomit (if it 
continue) ceasing to be bilious, by the stools acquiring a pale clay color, 
by the urine in from twelve to twenty-four hours becoming tinged with 
bile, and by the development a little later of general jaundice. The 
supervention of jaundice, after such symptoms as have been detailed, 
is almost pathognomonic of the passage of a biliary calculus, or at all 
events of a foreign body, along the common duct. The diagnosis 
cannot, however, be regarded as positive, unless the calculus be dis- 
charged per anum. And hence, in all cases of suspected hepatic colic, 
it is important to examine the faeces carefully from day to day. This 
should be done by diluting them with water, and passing them through 
a sieve with sufficiently small meshes to retain any small solid bodies 
which may be present in it. If the pain and other symptoms continue 
for some little time, more or less inflammation is likely to arise at the 
seat of disease ; tenderness and fulness may then come on, and more 
or less general febrile disturbance. And even after the escape of a 
calculus, such pain and fever, and even jaundice may continue for some 
little time. The passage of one biliary calculus is often, if not gener- 
ally, succeeded at irregular intervals by the passage of others, the later 
attacks being, however, as a rule, both milder and of shorter duration 
than the first. This repetition of similar attacks is a further indica- 



OBSTRUCTION OF THE HEPATIC DUCTS. 



741 



tion of the nature of the patient's malady. It may be added that the 
passage of biliary gravel, which has been sometimes discovered in the 
faeces, in large quantities, and inflammation of the neck of the gall- 
bladder, may be attended with many of the symptoms which indicate 
the passage of calculi. 

The consequences of the arrest of gallstones in the small intestine 
have been described under the head of intestinal obstruction; those of 
their long-continued or permanent retention in the common duct will 
be considered under that of obstruction of the hepatic ducts. 

Treatment. — The general treatment of gallstones is very unsatisfac- 
tory ; we can neither dissolve them nor remove them, nor if they have 
once formed can we prevent them from becoming larger. And even 
as regards prophylaxis, all that can be said is that those whom we be- 
lieve liable to them should eschew all such habits as seem likely to en- 
gender them. They should live wholesomely and abstemiously, and 
take a sufficiency of exercise daily. The habitual use of alkaline waters 
has been recommended, but the evidence in favor of their virtues is 
altogether valueless. For the paroxysm of hepatic colic, our main re- 
liance must be placed upon morphia or opium, given in sufficiently 
large doses, and sufficiently frequently, either by the mouth or hypo- 
dermically, to relieve the patient's sufferings. Belladonna has also 
been largely recommended, mainly with the object of relaxing spasm, 
and so aiding the onward passage of the stone, but it is certainty not 
so beneficial in its effects as opium. The inhalation of chloroform, short 
of producing insensibility, often affords the most signal relief. To as- 
suage the vomiting, Dr. Prout long ago recommended the use of copi- 
ous draughts of warm water, containing from one to two drachms of 
carbonate of soda to the pint. This practice is still largely followed, 
and believed to be efficacious. In addition to these remedial measures, 
the warm bath, hot fomentations to the epigastrium, and counter-irri- 
tants may generally be employed with advantage. 



OBSTRUCTION OF THE HEPATIC DUCTS. 

Causation. — Obstruction of the hepatic ducts is an incident of fre- 
quent occurrence, and of more or less importance in a large number of 
the morbid conditions of the liver, which have been already discussed ; 
it is also the most frequent cause of long-continued and intense jaun- 
dice, if not actually the most frequent cause of jaundice ; and on these 
grounds demands some special consideration. The causes of obstruc- 
tion are, in some cases, inflammatory thickening of the mucous mem- 
brane of the duct, or accumulation of inspissated mucus, or other forms 
of inflammatory exudation ; in some the presence of stricture ; in some 
the growth of polypoid tumors ; in some the impaction of calculi or 
other foreign bodies. In other cases they are to be sought in inflam- 
matory infiltration of the tissue of the lesser omentum, or of Glisson's 
capsule, or in the development in these situations of syphilitic, or carci- 



742 



DISEASES OF THE DIGESTIVE ORGANS. 



nomatous, or other growths involving or compressing the ducts. Fur- 
ther, tumors springing from the stomach, pancreas, or neighboring parts, 
and aneurisms may press upon the common duct and obstruct its channel. 

Morbid Anatomy. — Obstruction may take place in any of the ducts 
at any pari f their course ; and the effects on the ducts behind the im- 
pediment, 'a'nd on the liver-substance with which they are in relation, 
will be the same in kind wherever the obstruction is situated ; the bile 
becomes arrested fa its flow, and altered in character, the implicated 
ducts Undergo dilatation and other changes, and the liver-cells whose 
products tney receive become jaundiced, sometimes fatty, and some- 
times disintegrated. 

If complete obstruction take place in the common duct, the dilata- 
tion of ducts which ensues is almost universal; the common duct not 
very unfrequently attains the size of the duodenum, and the ducts rami- 
fying throughout the liver acquire proportionally large dimensions. 
The condition of the gall-bladder under such circumstances varies; 
sometimes it shrinks or shrivels up, sometimes it retains pretty nearly 
its normal bulk, sometimes it becomes, like the rest of the excretory 
apparatus, enormously distended. The consequences of obstruction as 
respects the biliary fluid itself, are that it generally gets thin and watery, 
and at the same time of a dark green or brown color ; but it becomes 
sometimes turbid from admixture with mucus or pus ; sometime sabu- 
lous from the deposition of solid matter, pigment, or cholesterin; 
sometimes sanguineous ; and sometimes (when the bile ceases to form 
or to flow) transparent, colorless, and viscid. The last kind of fluid 
may be met with in the gall-bladder when, after closure of the cystic 
duct, it dilates (as occasionally happens) into a mucous cyst. The con- 
sequences, as regards the walls of the ducts, are also very various. In 
most cases they become thickened, but in some they become attenuated, 
in some inflammation with excess or modification of secretion takes 
place, in some ulcerative destruction. In the last case perforation of 
the common duct may occur, with the development of an abscess in 
its vicinity, or with rupture in the peritoneum ; or even more or less 
general destruction of the walls of the bile-ducts may ensue with the 
formation in their place of irregular biliary channels, bounded by the 
eroded hepatic tissue, and communicating, it may be, with branches of 
the portal vein. Such channels may be converted into branching ab- 
scesses. The effects of obstruction on the liver generally are, in the 
first instance, gradual and uniform increase of bulk, which may be main- 
tained for several months ; and then gradual atrophy, the organ how- 
ever not so much shrinking in all its dimensions as becoming wrinkled, 
thin, and flabby in consistence. The hepatic texture becomes soft, flabby, 
and oedematous (yielding on pressure a considerable quantity of thin 
greenish fluid) and jaundice, or before long of a dark greenish hue. 
This color is at first most marked in the centres of lobules, but ulti- 
mately becomes generally diffused. On microscopic examination, the 
hepatic cells are usually found more or less deeply bile-stained, and 
often containing granular pigment and oil-globules. In some cases the 
cells after a time undergo degeneration; and all that remains of the 
hepatic texture may then be the framework of connective tissue, vessels, 



OBSTRUCTION OF THE HEPATIC DUCTS. 



743 



and the like, together with a greater or less abundance of free oil- 
globules, granules of precipitated pigment, and cell-nuclei. The tis- 
sues moreover usually yield an abundance of leucin and tjprosin. 

It has been assumed throughout the foregoing account *l.at the ob- 
struction is complete and permanent ; it need scarcely said that 
obstructions are often merely temporary, that whether tt. porary or 
permanent they are not unfrequently incomplete, and that under either 
of these circumstances there will be more or less 'mportant modifi- 
cation in the progress and consequences of the secondary pathological 
lesions. < ■ 

Symptoms and Progress. — It is always important, for the sake both 
of prognosis and of treatment, but often quite impossible, to determine 
the exact cause of obstructive jaundice. Our diagnosis in each case 
must rest on a careful consideration of its history and progress and on 
a close investigation of the phenomena which come under our imme- 
diate observation. It is not, however, so much with this subject that 
we have now to deal as with the special symptomatic consequences of 
obstruction ; and indeed these have already been pretty fully considered. 
They may be divided mainly into those dependent on absence of bile 
from the alvine evacuations, those due directly to the changes going on 
in the liver, and those arising from the accummulation of bile and of 
effete matters in the blood. The chief consequences of the absence of 
bile from the bowels have been already discussed. 

Alteration in the bulk of the liver is a sign of considerable value. 
Its primary increase of size is indicated on the one hand by the gradual 
rise of the hepatic d illness into the chest, on the other hand by the 
gradual emergence of its lower edge from under the ribs and its exten- 
sion for two or three inches below its normal level. If the gall-blad- 
der also undergo distension, it may generally be readily recognized as 
an elastic or fluctuating swelling coming out from beneath its accus- 
tomed notch. In rare cases the distended common duct has itself been 
felt as a fluctuating tumor. When the later atrophic changes set in the 
enlargement of the liver ceases, and the organ undergoes slow diminu- 
tion in bulk ; but this change reveals itself less by general shrinking 
than by diminution of thickness, and the free edge of the liver often 
becomes peculiarly thin, and may then, if the abdominal walls be 
flaccid and spare, be readily grasped between the finger and thumb. 
Some degree of fulness, weight, tenderness, or pain is not unfrequent 
in the situation of the liver, during the progress of its enlargement, 
especially if inflammatory changes supervene. 

The jaundice of obstructive disease is generally peculiarly intense; 
it first reveals itself by the presence of bile-pigment in the urine at the 
end of from twelve to thirty-six hours after the bile has ceased to flow 
into the bowels. Yellowness of the conjunctiva? and of the skin 
usually supervenes in the course of the third day. If the obstruction 
continue, the intensity of the jaundice rapidly increases, and after a 
time tends to asume a greenish or brownish tint. The color is liable 
to variations of intensity even when no discharge of bile into the 
bowels takes place, and by no means necessarily increases with the 



744 



DISEASES OF THE DIGESTIVE ORGANS. 



duration of the case ; indeed it not unfrequently happens that it under- 
goes manifest diminution during the later periods of the disease. 

It is chiefly in jaundice from obstruction that we may look for the 
occurrence of many of those additional phenomena which have already 
been adverted to, such as yellow vision, itching and eruptions on the 
skin, and petechial and other forms of hemorrhage; and it is with this 
alone that vitiligoidea has any connection. It may be added that 
there is, as a rule, no elevation of temperature, and that there is no 
necessary affection of the tongue or loss of appetite. 

It is almost needless to say that, in those cases in which the ob- 
struction is temporary only, in those in which the obstruction of the 
main duct is, and remains, incomplete, and in those in which (as in 
cirrhosis) the impediment to the escape of bile involves the minuter 
tubes only, the symptoms will vary more or less widely from those 
which have just been detailed; especially the evacuations will still 
probably contain bile, the liver will undergo little or no enlargement, 
the jaundice will be slight, and the other symptoms which associate 
themselves with these conditions will be developed slightly or late, or 
not at all. 

The duration of life in cases of jaundice with complete obstruction 
varies a good deal. In some cases the patient dies in the course of a 
few weeks; in some he survives for periods varying between six and 
twelve months; while occasionally life is prolonged for two, three, or 
more years. The causes of death also are various. Sometimes death 
is due to rupture of the hepatic or common duct, or of the gall-bladder, 
with consequent peritonitis ; sometimes to the supervention of hepatic 
inflammation with suppuration .and some one or other of their results; 
sometimes to intestinal or other haemorrhage ; sometimes to so-called 
"biliary toxaamia;" most frequently, however, it results from grad- 
ually increasing emaciation and debility. Further, patients enfeebled 
by this disease are very apt to be attacked with pneumonia, dysentery, 
dropsy, or other complications, and to be thus carried off. In some 
cases recovery takes place even after complete obstruction has lasted 
for a considerable length of time ; the indications of this event are the 
reappearance of bile in the faeces, the gradual disappearance of pigment 
from the skin and from the urine, and in association therewith general 
improvement in the patient's health. 

Treatment. — In the treatment of jaundice from obstruction our first 
object should of course be to remove the mechanical obstacle to the 
escape of bile from the liver. It need scarcely, however, be said that 
this can never be effected excepting by indirect measures, and in a 
large proportion of cases never effected at all. But in reference to this 
subject Ave must refer the reader to those articles which deal with the 
various conditions to which obstruction may be due. The question we 
have here specially to consider is : How shall the jaundice and the 
consequences it entails be best treated? Unfortunately, we can do 
little, and that little is mainly hygienic. The patient's bowels should 
be regulated if necessary by mild laxatives ; the functions of the kid- 
neys and of the skin (by which emunctories bile is now almost solely 
eliminated) should be promoted by the use of diluents, diuretics, warm 



JAUNDICE WITHOUT OBSTRUCTION. 



745 



clothing, and warm baths with rubbing or shampooing ; his appetite 
should be sustained and his gastric digestion improved if necessary by 
vegetable tonics or stomachics, with which the carbonates of the 
alkalies may often be beneficially combined; his general health should 
be maintained partly by the exhibition of vegetable tonics and iron, 
partly by the habitual use of nutritious unstimulating food from which 
fatty matters and alcohol are as far as possible excluded, partly by at- 
tention to hygienic conditions, more especially to warm clothing, the 
avoidance of chills or sudden vicissitudes of temperature, change of 
scene, moderate exercise, and early hours. Of particular remedies it 
may be observed that Frerichs recommends lemon-juice as a valuable 
diuretic in these cases, and that Dr. George Harley advocates the use 
of inspissated ox-gall in gelatin capsules, to be given in doses of from 
five to ten grains two or three hours after each meal. It need scarcely 
be added that when complications arise — gastric catarrh, diarrhoea, 
haemorrhage, or head symptoms — these will each probably need their 
appropriate treatment. In those cases in which the gall-bladder be- 
comes excessively distended the question as to the propriety of punctur- 
ing it may arise. The operation is obviously one not to be lightly 
entertained, and to be performed with the most ample precautions. 



JAUNDICE WITHOUT OBVIOUS OBSTRUCTION OF 

DUCTS. 

Causation. — The varieties of jaundice here referred to are more par- 
ticularly those which occur in the specific febrile disorders, such as 
intermittent fever, yellow fever, relapsing fever, and pyaemia. It is 
possible too, that under the same head must be included the jaundice 
which occasionally attends pneumonia, rheumatism, snake bites, phos- 
phorus poisoning, and those other morbid conditions of the liver in 
which the secreting cells are directly involved. The jaundice which is 
said to arise under the influence of strong mental disturbance, and that 
of new-born babes, may also possibly be placed in the same class. It 
must be remarked, however, that there is still considerable uncertainty 
in respect of the intimate pathology of the jaundice attending these 
various affections ; it is very probable that, as Virchow holds, ca- 
tarrhal obstruction of the intestinal portion of the common duct may 
eventually be proved to be the cause of the jaundice in some of them ; 
there seems little doubt that in others it is actually due to changes 
going on in the coloring matter of the blood, within the blood itself; 
and it is possible no doubt that in some of them it may be the conse- 
quence, as Frerichs holds, of an abnormal diffusion of bile, arising in 
some alteration in the supply of blood to the liver, and defective meta- 
morphosis or consumption of bile in the blood ; and in some, as Dr. 
Murchison believes, of excessive reabsorption of bile with or without 
excessive secretion. 

Morbid Anatomy. — In most of the cases here referred to the liver is 



746 



DISEASES OF THE DIGESTIVE ORGANS. 



found post mortem to be pale and anaemic, and soft or flabby, and the 
hepatic cells either quite normal, or, as especially in phosphorus 
poisoning, unusually granular or studded with droplets of oil ; in 
some the generally pallid tissue presents patches of still more marked 
pallor, which are often separated from the surrounding parts by wide 
but irregular zones of slight congestion. The appearances, as a rule, 
are certainly not very striking, and scarcely indicative of serious he- 
patic disease. 

Symptoms. — The jaundice is almost without exception very slight. 
It creeps on gradually ; it does not attain any intensity in the skin ; 
and the pigment passed with the urine is in very small quantity. 
Moreover, the motions almost always still contain bile. There is no 
doubt that in many of these cases the symptoms which the patient 
presents are extremely grave. Yet there is no good reason to believe 
that as a rule they are in any important degree due to the hepatic dis- 
order ; for while the grave symptoms are usually those which charac- 
terize the disease which the jaundice complicates, those cases in which 
jaundice appears are not generally more serious than those from which 
it is absent, and the jaundice does not usually bring with it any specific 
symptoms. 

Treatment. — The forms of jaundice now under consideration rarely 
call for special treatment. Their presence may, however, furnish a 
hint as to the desirability of employing laxatives, and of promoting 
the action of the skin and kidneys. 



MALIGNANT JAUNDICE. {Yellow Atrophy of the Liver.) 

There is one form of disease in which jaundice is associated with 
a remarkable lot of symptoms, which may for convenience, if not on 
other grounds, be separated from the group of cases which has just 
been considered ; it is that which is sometimes termed malignant jaun- 
dice, and to which Rokitansky has given the name of yellow atrophy 
of the liver. 

Causation. — Cases of malignant jaundice have been observed chiefly, 
if not solely, among adults, and among women far more frequently 
than men. Moreover, in a very large proportion of cases, the suf- 
ferers have been women during the period of pregnancy. It is also 
a remarkable fact that the onset of the disease appears very frequently 
to have been determined by some sudden and intense mental emotion. 
Among other assigned causes may be enumerated syphilis, typhus, and 
miasm. 

Symptoms and Progress. — Malignant jaundice frequently comes on 
without premonitory signs, but in a considerable number of cases is 
preceded for a few days, or even for a few weeks, by slight symptoms 
of gastro-intestinal catarrh, with which probably, sooner or later, some 
degree of jaundice is associated. Among the first symptoms which 
usually arise to indicate the gravity of the attack are vomiting, and 



MALIGNANT JAUNDICE. 



747 



especially the vomiting of coffee-ground fluid, due to gastric haemor- 
rhage, intense headache, irritability, and restlessness. To these soon 
succeeds delirium, which is sometimes low and muttering, sometimes 
noisy, and very frequently violent and maniacal. The patient's man- 
ner is agitated, there is generally more or less tremulousness of his 
limbs, and in a large proportion of cases convulsions soon manifest 
themselves. These may vary in character ; they may be general or 
local ; and they may present the features of simple rigors, or assume 
an epileptiform or tetanic form. After a short time, the condition of 
delirium or convulsion passes into one of quietness and stupor, which 
gradually deepens into profound coma, usually attended with dilated, 
inactive pupils and stertorous breathing. But, besides the remarkable 
combination and sequence of symptoms here enumerated, other phe- 
nomena present themselves which are of considerable significance and 
importance in reference to diagnosis. The pulse during the earlier 
period of the disease, or that of excitement, is characterized by re- 
markable and sudden variations in frequency, but is generally abnor- 
mally quick ; with the supervention of coma, however, it becomes 
more uniformly rapid, and at the same time more and more feeble, 
until probably it can be no longer felt at the wrist. The tongue soon 
becomes coated, and generally before long assumes the typhoid char- 
acter ; it gets dry and brown or black, and sordes accumulate upon 
the teeth. There is very often, but not invariably, some uneasiness 
and tenderness in the hepatic region ; and in addition, it can often be 
determined by careful examination that there is a gradual diminution 
in the area of hepatic dulness. The bowels are usually confined ; and 
the motions passed in the course of the disease present a gradual dimi- 
nution, and at length, it may be, total absence of biliary color. The 
urine is usually secreted in normal quantity, and acid; but it becomes 
jaundiced in a greater or less degree, urea and phosphate of lime di- 
minish, and sometimes wholly disappear, to be replaced by leucin and 
tyrosin and extractive matters, which, when the urine cools, sometimes 
form a peculiar greenish-yellow sediment. The skin is usually cool 
and dry. The jaundice, which sometimes precedes, sometimes follows, 
and sometimes appears simultaneously with, the other initial symptoms 
of the disease, increases in depth with the duration of the malady, but 
rarely, if ever, attains any high degree of intensity. There are yet 
two other features of striking importance ; the one is the total absence 
of febrile temperature, the other a general tendency to haemorrhage ; 
this latter tendency shows itself sometimes by hsematemesis, sometimes 
by the appearance of petechia? and bruise-like extravasations beneath 
the skin, sometimes by more or less profuse discharges of blood from 
the nose, bowels, and other mucous surfaces. 

The most striking features in the clinical aspect of malignant jaundice 
are the combination of slight jaundice with grave cerebral disturbance, 
haemorrhage from and into various organs and tissues, profound change 
in the composition of the urine, absence of fever, and the almost inva- 
riably fatal issue of the disease. Death may occur within twelve or 
twenty-four hours, generally between the second and fifth day, and is 
very rarely delayed beyond a week. 



748 



DISEASES OF THE DIGESTIVE ORGANS. 



Morbid Anatomy. — In all typical cases of the disease the phenomena 
observed post mortem are remarkable and characteristic. The most 
obvious change is manifested by the liver. This may be of natural 
size, but is usually shrunk to half or even one-third of the normal bulk, 
its surface being then wrinkled and flabby. On section it is found to 
be of a nearly uniform pale yellow color, with little or no indication of 
its constituent lobules, and little or no evidence of vascular injection. 
Frerichs says that in some cases the lobules are separated from one 
another by a dirty grayish-yellow substance. The bile-ducts and gall- 
bladder usually contain either colorless mucus, or a thin fluid, only 
very slightly tinged with bile. On microscopic examination, the hepatic 
cells are found to have disappeared more or less completely — in some 
cases not one is discoverable; and in their place may be observed either 
simple granular matter, or this intermingled with oil-globules and 
precipitated bile-pigment. Leucin and tyrosin may also sometimes be 
recognized in the hepatic substance and in the hepatic veins. There 
is usually some enlargement of the spleen. The only other morbid 
phenomena of importance are an occasional fatty change of the glan- 
dular epithelium of the kidneys ; extravasations of blood (usually pe- 
techial) beneath the surface of the peritoneum, pleura?, and pericardium, 
and in connection with the gastro-intestinal and other mucous mem- 
branes, and occasionally in the substance of the lungs, liver, spleen, 
and kidneys; and the presence in the blood (which does not as a rule 
display any change visible to the naked eye) of large quantities of leu- 
cin and urea. 

What the nature of the malady under consideration is, is by no 
means satisfactorily established. By some it is regarded as a primary 
disease of the liver. Frerichs, who, following Bright, takes this view, 
looks upon it as a parenchymatous inflammation of the organ, attended 
with little exudation, but with obstruction to the passage of blood 
through the vascular network at the periphery of the lobules, and con- 
sequent degeneration and death of the hepatic cells. According to this 
view, the jaundice and all the characteristic symptoms of the disease 
are secondary to the hepatic lesion. Some, on the other hand, look 
upon the hepatic affection as the consequence of some general blood- 
disease, due either to the absorption of some noxious chemical sub- 
stance or to a poison of organic origin having some affinity with those 
of the infectious fevers, or with that of pyaemia. In this latter point 
of view some of the graver symptoms would be referable to the primary 
disease of which the hepatic disorder is a consequence, but others might 
still be attributed to the morbid condition of the liver. It would not 
be difficult to adduce plausible arguments either against or for either of 
these hypotheses. We may, however, point out that while, on the one 
hand, there is nothing in the clinical phenomena of these cases to indi- 
cate their inflammatory origin ; there is, on the other hand, ample 
proof, from the occasional supervention of the symptoms of malignant 
jaundice in cases of jaundice from occlusion of ducts, that extensive 
destruction of the secreting structure of the liver, with suppression of 
bile, is fully competent to induce all the phenomena of the disease un- 
der consideration. We must confess, indeed, that, while not quite 



DISEASES OF THE PANCREAS. 



749 



committing ourselves to the inflammatory Origin of the hepatic changes, 
we are disposed to regard the disease as primarily hepatic. 

Treatment. — Nothing can well be less satisfactory than our knowl- 
edge in reference to the treatment of malignant jaundice. Active pur- 
gation has been recommended, especially in the early stage ; it is diffi- 
cult, however, to understand why. Again, those who look upon the 
disease as of inflammatory origin advocate the local abstraction of 
blood, and other antiphlogistic measures, during the inflammatory 
stage. But unfortunately this, if it exist at all, exists only during that 
preliminary period in which there is nothing to distinguish cases of 
malignant jaundice from cases of catarrhal affection of the biliary ducts. 
Considering that in this disease there is a large accumulation of effete 
matter in. the blood, on which it seems probable that some of the grave 
symptoms are dependent, there are grounds for the employment of 
diuretic and diaphoretic measures. In the absence of more obvious 
indications, we must either do nothing, or treat the more prominent 
symptoms ; that is, so far as we are able, check vomiting, arrest haemor- 
rhage, overcome constipation, proitiote the action of the skin and kid- 
neys, soothe during the stage of excitement, and during that of stupor 
and coma and failing strength employ counter-irritants and stimulants. 



(5.)_DISEASES OF THE PANCREAS. 

Introductory Remarks. — Very little is known of any clinical value 
about the diseases of the pancreas. This is due no doubt partly to the 
comparatively small size and deep situation of the gland, partly to the 
fact that its functions have much in common with those of the salivary 
and duodenal glands, and even with those of the liver itself, but chiefly 
perhaps because it is rarely affected excepting secondarily or in associa- 
tion with diseases of neighboring organs. 

In reference to the diagnosis of pancreatic disease, we must recollect 
that this organ is situated in front of the aorta and behind the stomach, 
deep in the epigastric region, and on the level of the first lumbar ver- 
tebra ; that any tumor which may be developed in it will be discover- 
able in this situation only (a situation however which may be equally 
affected by aneurisms of the aorta or cceliac axis, or tumors involving 
the posterior wall of the stomach, or originating in the retro-peritoneal 
glands) and will probably be immovably fixed there; and that any 
pain and tenderness which may attend its lesions will probably be re- 
ferred to the depth of the epigastric region and to the back, in the sit- 
uation of the upper lumbar and lower dorsal vertebrae. We must also 
recollect that the function of the organ is to secrete a large quantity of 
fluid which differs little from ordinary saliva either in its chemical 
composition or in its office, and is an important agent in the em unifi- 
cation of fat, in the conversion of starch into dextrin and sugar, and 
in the reduction of albuminous matters into a form favorable for assimi- 
lation. It may therefore be reasonably believed that the retention or 



750 



DISEASES OF THE DIGESTIVE ORGANS. 



suppression of the pancreatic fluid will be attended with more or less 
serious impairment of nutrition, and if the food contain much starch 
or fat, with the unwonted appearance of starch or fat in the evacua- 
tions. The abundant discharge of fat by stool has indeed been not 
unfrequently noticed in cases in which the pancreas has been seriously 
diseased. 

Hyperemia and Inflammation. — Of these conditions but little can be 
said; they are occasionally recognized post mortem, but for the most 
part in cases where no suspicion of pancreatic disease was entertained 
during life. Abscesses are sometimes discovered in the gland, and oc- 
casionally large abscesses, but they are usually small and of pysemic 
origin. Catarrhal inflammation of the duct is probably not uncommon 
in connection with the same affection of the common hepatic duct, and 
may, like that, lead to temporary or even permanent obstruction. In 
chronic ulcer of the stomach the subjacent pancreas is not unfrequently 
implicated in the course of the extension of ulceration, and thus its 
eroded substance may come to form the floor of the gastric ulcer. 

Morbid Growths. — The pancreas is not unfrequently the seat of such 
formations ; but they are rarely, if ever, of primary origin within it ; 
they are sometimes a consequence of the generalization of malignant 
tumors, but are much more frequently due to extension of disease from 
the stomach, retro-peritoneal glands, or peritoneum. It is, however, in 
carcinoma of the pyloric extremity of the stomach that the pancreas 
most frequently becomes involved. Of the several varieties of malig- 
nant disease to which it is liable, scirrhus is the most common ; but the 
encephaloid, colloid, and melanotic forms have each been met with. 

Calculi are occasionally discovered in the pancreatic ducts, and more 
especially in the principal duct. They have the same chemical and 
other characters as other salivary calculi, consisting mainly of phos- 
phate of lime with some animal matter, and vary from minute granules 
up to the size of a filbert. When small they are sometimes present in 
vast numbers ; when large they are usually solitary, and more or less 
completely obstruct the duct in which they lie. 

Obstruction of the Pancreatic Ducts. — When these channels are 
blocked up, whether by calculi or stricture, or by their compression by, 
or involvement in, malignant and other forms of growth, the ducts 
behind undergo gradual dilatation from the accumulation of secretion 
within them. The chief enlargement occurs in the principal duct, 
which becomes elongated and tortuous, irregular in form, and some- 
times sufficiently dilated to admit the finger. The secondary ducts 
also become dilated, but in a less degree ; and the whole organ conse- 
quently increases in bulk, and on section appears at first sight to be 
made up of a congeries of cysts : the secreting tissue between them being 
more or less atrophied. Cysts, apparently due to the dilatation of an 
obstructed duct of small size, are occasionally discovered in glands 
which are in other respects healthy. Their only pathological impor- 
tance arises from the fact that they may, from their size and situation, 
be readily mistaken for tumors or cysts of much more serious import. 
They may attain the size of an orange. 

Symptoms and Treatment. — It would be a waste of time to discuss 



DISEASES OF THE KIDNEYS. 



751 



the diagnosis of the various lesions which have just been passed in 
review ; the special phenomena which must be looked for as indicative 
of pancreatic disease have been already sufficiently considered ; and for 
the recognition of additional features special to each variety of lesion, 
the practitioner must be guided by his general knowledge of pathology 
and of the pathology of the pancreas. In the great majority of cases 
pancreatic disease will doubtless remain undetected during life. 

It would be equally a waste of time to enter upon the discussion of 
the treatment of pancreatic affections. 



VI.— DISEASES OF THE GENITO-URINARY ORGANS. 

(1.) — DISEASES OF THE KIDNEYS. 

INTRODUCTORY REMARKS. 

General Physiological and Pathological Considerations. 

The urinary organs comprise the kidneys, ureters, bladder, and ure- 
thra. The diseases of all these parts are of high interest to the phy- 
sician ; but those of the kidneys and ureters come more especially under 
his observation and treatment, and it is to them mainly, therefore, that 
attention will be directed in the following pages. 

The sole function of the kidney is to separate from the blood, in 
association with water, a number of effete, waste, and surplus matters 
which are constantly being added to the blood from various sources. 
But the urine, as it escapes from the urethra, contains in greater or less 
proportion certain additional matters, mucus and the like, which are 
yielded to it by the various mucous surfaces over which it passes, and 
by the glandular organs which open upon them. 

The urine, thus constituted, varies in its composition within wide 
limits, even in health. In disease, where the nutritive and destructive 
processes are variously modified, and where the functional activity of 
important organs is in various degrees diminished, impaired, or exalted, 
the composition of this fluid undergoes still greater variations; and, 
indeed, there are some cases (such, for example, as that of diabetes) in 
which, the kidney remaining sound, the nature of the disease under 
which the patient labors is revealed almost solely by the peculiarities 
which the urine presents. But especially the composition of the urine 
is largely and importantly modified by diseases of the urinary organs, 
which tend on the one hand to impede the discharge from the blood of 
the proper urinary constituents, and on the other hand to add to the 
urine matters which are wholly foreign to its normal constitution. It 
is obvious, therefore, that the careful investigation of the urine may be 



752 



DISEASES OF THE GENITO-URIN ARY ORGANS. 



expected to throw important light, not only on the varying processes 
connected with healthy nutrition, but also on the pathology of many of 
those morbid conditions in which the kidneys are not distinctly impli- 
cated, and above all on the nature of the diseases of the kidneys them- 
selves and of the several organs which are in relation with them. 

But again, when the urinary organs are the seat of disease, and 
oppose (as they then generally do) a more or less complete obstacle to 
the elimination of urea and other such matters from the blood, it is 
clear that this fluid must soon become surcharged with effete and pre- 
sumably injurious matters of a specific kind, and that we must, there- 
fore, expect specific morbid consequences sooner or later to ensue. 

It is clear also that many diseases of these organs must be attended 
with both local and general indications and symptoms which are totally 
independent of the functional derangements which are associated with 
them : local phenomena, such as pain and tumor ; general phenomena, 
such as inflammatory fever and some forms of cachexia. 

The morbid phenomena, therefore, which are associated with, and 
result from, diseases of the kidneys, may be properly and conveniently 
divided into : first, those which are special to these organs and depend 
directly on the impairment or perversion of their normal functions ; 
and, second, those which in a certain sense are common to these and 
other similarly affected constituent portions of the body. 

In accordance with the foregoing observations, we propose to give 
a brief account of the composition of the urine in health and disease ; 
of the* specific consequences of the retention of urea and other such 
matters in the blood ; and of the non-specific morbid phenomena which 
attend and characterize lesions of the urinary organs. 

Characters and Composition of the Urine in Health. 

The urine is a transparent, limpid, straw or amber-colored fluid, of 
saline taste, and for the most part of acid reaction, which deposits, on 
standing, a filmy cloud of mucus, and occasionally an opaque, reddish, 
powdery sediment. Its acidity increases for a few days with exposure 
to the air, and at the same time urates, uric acid, and oxalates are de- 
posited. Then it undergoes putrefaction, becomes alkaline and ammo- 
niacal ; earthy matters, including crystals of triple phosphate, fall, and 
bacteria and torutae make their appearance in it. 

The quantity passed in twenty- four hours fluctuates within wide 
limits ; it may, however, be reckoned usually as between two and three 
pints in the adult, but may range from one to four pinis. The specific 
gravity also presents a wide range; it commonly lies between 1015 
and 1025, but may temporarily fall to 1005 or less, or rise to upwards 
of 1030. The acidity, which, when the urine is emitted from the 
bladder is an almost unfailing characteristic of it, is liable to a good 
deal of variation of intensity ; and, indeed, as Dr. W. Roberts shows, 
that which is secreted an hour or two after meals is generally alkaline, 
although its alkalinity is commonly masked by its admixture in the 
bladder with acid urine already there or subsequently added to it. The 
acidity depends mainly on the presence of acid phosphates and urates, 
and in some degree also on traces of lactic, oxalic, and other acids. 



URINE IN HEALTH. 



753 



The degree in which the specific gravity of urine exceeds that of 
distilled water depends on the solid matters — the special urinary con- 
stituents — which are contained in it. The proportion which these hold 
to the watery constituent may be approximately estimated, according 
to Trapp's formula, by doubling the last two figures of the number 
which indicates the specific gravity. Thus, 1000 parts of urine with 
a specific gravity of 1015 contain 30 parts of solids; and 1000 parts of 
urine with a specific gravity of 1025 contain 50. Hence the amount 
of solid matter in healthy urine usually varies from three to five per 
cent. It is generally, however, far more important to know the actual 
amount of solid matter that is passed daily than the ratio which the 
solid matter holds to the very variable quantity of water with which 
it is mixed. This knowledge can be gained by collecting and mixing 
all the urine that is passed in the course of twenty-four hours, and then 
examining quantitatively a measured portion of its bulk, or, more 
readily though less accurately, by the method above given. 

The solid matters of the urine are very numerous, and they vary 
largely, both in the relative proportions in which they are excreted and 
in their aggregate amount. The urea especially is remarkably modi- 
fied by age, sex, diet, and other circumstances, so that the amount 
which may be taken as the average may be halved or doubled inde- 
pendently of any impairment of health. The following table is de- 
signed to show at a glance the relative proportions of the chief con- 
stituents contained in an average specimen of the urine of an adult, and 
the total quantities of each which might in such a case be discharged 
in twenty-four hours. The specific gravity is assumed to be 1025, and 
the temperature 32° : 



Urinary constituents. 


Percentage 
composition. 


Daily aggregate in grains. 


Urea, CH 4 N 2 0 

Uric acid, C 5 H 4 N 4 0 3 

Kreatinin, .... C 4 H 7 N 3 0 
Hippuric acid, . . . HC 9 H 8 N0 3 
Pigment, mucus, odorous ~) -™ , 

matters, xanthin, etc., } Extractlve 
Total organic matters, 

Lime, 

Total fixed salts, 


95.000 

2.500 
.042 
.075 
.075 

.600 

3.292 

500 
.150 
250 
175 
600 
018 
015 

1.708 


19000.0 

500.0 
8.5 
15.0 
15.0 

120.0 

658.5 

100 0 
30.0 
50.0 
35.0 
120.0 
3.5 
3 0 

341.5 




100.000 


20,000.0, or 45£ ozs. 



48 



754 



DISEASES OF THE GENITO - URINARY ORGANS. 



Characters and Composition of the Urine in Disease. 

The variations in the quality and quantity of the urine in health 
are so wide, that it is often extremely difficult, and sometimes impos- 
sible, to be certain, from the examination of this fluid alone, whether 
it should be regarded as healthy or morbid. When matters are added 
to it which are wholly foreign to its composition, and cannot be ascribed 
to the influence of special articles of food or other substances which 
have been received into the blood, no doubt as to its morbid character 
can be entertained. Again, when, independently of external conditions 
and habits of life, the urine habitually deviates largely from the mean, 
whether in the direction of excess or diminution, as regards either its 
total bulk or the amount of any of its more important constituents, 
no doubt as to its un healthiness is possible. And again, when sedi- 
ments form habitually, even though the sedimentary matters be normal 
constituents of the urine, and the chemical composition of the urine 
itself reveals no appreciable departure from health, the unhealthy con- 
dition of the secretion is indisputable. 

In the following account of the urine, which is intended to be mainly 
pathological, it will be convenient, after briefly adverting to the physi- 
cal characters of morbid urine, to incorporate most of those physiologi- 
cal and chemical remarks in reference to its normal constituents, which 
might seem to belong strictly to the previous section. 

Physical Characters. — The quantity of urine passed differs very 
largely in different diseases. In some general affections, as cholera 
and collapse — especially collapse connected with lesions of the abdomi- 
nal organs — the urine is absolutely suppressed. In most febrile dis- 
orders, and in inflammations, it is much diminished. In other cases, 
on the contrary, as after hysterical paroxysms, in the conditon known 
as diabetes insipidus, and especially in diabetes mellitus, it becomes 
profuse. Again, the urine is generally greatly diminished when acute 
nephritis is present ; it may even be temporarily suppressed from this 
cause. Its discharge occasionally also becomes arrested in consequence 
of obstructive disease of the ureters. On the other hand, in chronic 
renal disease it is often largely increased. The amount of solid con- 
stituents present is not necessarily in relation with the quantity of 
urine voided. No doubt, generally, the more scanty the urine is, the 
higher is its specific gravity, and the larger the proportion which the 
solid matters hold to the water. But, on the other hand, in most 
febrile diseases there is an actual increase in the nitrogenous constitu- 
ents, even while there is marked diminution in the total bulk of urine 
passed ; and in the profuse urine of diabetes mellitus the quantity of 
solid matters secreted is so large, that the specific gravity often rises to i 
1040, 1050, or even 1060 degrees. 

The urine in disease may present the same reactions as in health, or 
it may be preternaturally acid, or, on the other hand, it may be neutral 
or alkaline. Alkalinity of urine may be due to the presence either of 
ammonia or of fixed alkalies. The presence of ammonia is due to the 
decomposition of urea, and arises only after the urine has been secreted 
by the kidneys. It mostly occurs in connection with chronic inflam- 



URINE IN DISEASE. 



755 



mation of the mucous lining of the bladder and other parts, and the 
secretion therefrom of morbid mucus. The persistence of alkalinity 
from the influence of fixed alkalies, if it be not dependent on peculi- 
arities of diet or medicine, is generally connected with the existence of 
affections characterized by anaemia and debility. 

The presence of acidity may be recognized by the use of blue lit- 
mus paper, which becomes red under the influence of acids, and the 
presence of alkalinity by the employment of red litmus paper, which 
is rendered blue by alkalies, or of yellow turmeric paper, which be- 
comes brown. If the alkalinity be clue to ammonia, the test-paper 
changed under its influence returns to its original color on being dried. 

As regards color, smell, and the presence of turbidity or sediment, 
all that we deem it necessary to say will be incorporated in our subse- 
quent account of those urinary constituents to which these conditions 
are severally mainly due. 

Urea. — This is by far the most abundant and important of the 
urinary solids. It is furnished by the destructive metamorphosis of 
the nitrogenous tissues of the body and elements of the food, and con- 
tains nearly the whole of the nitrogen which was originally incorporated 
with the substances from which it is derived. Its quantitative varia- 
tions are so great during health, that it is impossible, in a few words, 
to explain when and to what degree such variations are to be regarded 
as morbid. It may be pointed out, however, that urea is almost always 
largely increased during the febrile stages of inflammatory and febrile 
disorders, and in diabetes, that it is diminished in nephritis and other 
inflammatory or structural diseases of the kidney itself, in anaemia and 
in starvation, and that it has been found to be entirely absent, occa- 
sionally at least, in yellow atrophy of the liver. Urea is a feeble base, 
and exceedingly soluble, and has, therefore, under ordinary circum- 
stances, no visible influence over the condition of the urine. It forms 
no sediment, and cannot be detected in it except by chemical examina- 
tion. Under the influence of the mucus of the bladder, and under 
other circumstances, it is readily converted, with the aid of water, into 
carbonate of ammonia. 

Uric Acid and Urates. — Uric acid is derived from the same source 
as urea, and is liable to slight fluctuations in quantity under much the 
same circumstances as urea. It is readily decomposed, by oxidiz- 
ing agents, into several less complex substances, of which urea (to 
which it contributes the whole of its nitrogen) is the most important. 
It may, in fact, be regarded as representing a stage in the conversion 
of albuminous matter into urea. It is exceedingly insoluble in water, 
and hence, when free in the urine, forms a crystalline deposit. It is, 
however, generally combined with a base, especially ammonia or soda, 
and in this form is much more soluble, though still liable to form a 
sediment. The main interest, indeed, attaching to the presence of uric 
acid and urates in the urine, resides in the fact of their tendency to 
become deposited, and to take part in the formation of gravel and of 
calculi. Free uric acid often falls during the acid fermentation taking 
place in urine which is kept, and, when met with in fresh urine, it is 
generally in consequence of that fluid having an excessive degree of 



756 DISEASES OF THE GENITO - URINARY ORGANS. 



acid reaction. It may readily be recognized by the character of its 
crystals. These may form reddish grains, visible to the naked eye, or 
are merely microscopic objects. The forms which they assume are 
various, and depend largely on the quality of the urine in which they 
are found. They are, however, generally lozenge-shaped or rhom- 
boidal, with the angles more or less rounded, and vary in thickness so 
as to form, on the one hand, mere films, on the other, short flattened 
cylinders or prisms. When abundant, they are often grouped together 
into stellate or variously shaped clusters. If any doubt as to the nature 
of the deposit exist, it may be set at rest by converting it into murex- 
ide. This may be done by placing a little of the deposit in a porcelain 
dish, adding to it a drop or two of strong nitric acid, and heating the 
whole to dryness. If now, when the residue is cool, a rod dipped in 
caustic ammonia be applied to it, the beautiful purple color, character- 
istic of murexide, is developed. Urates, comprising chiefly those of 
ammonia and soda, are often deposited from urine in an amorphous 
condition, forming a powdery sediment which clings to the vessel, and 
which, from its attraction for the coloring matter of the urine, varies 
in tint from a light fawn to pink. Like uric acid itself, they generally 
precipitate in acid urine, but, unlike uric acid, they mostly fall in con- 
centrated urine, especially when it becomes cool. The formation of 
uratic sediments often occurs in the urine of healthy persons, especially 
in cold weather ; it often, however, attends and indicates the presence 
of catarrh or other febrile states, or derangements of the liver or other 
chylo-poietic viscera. Amorphous urates are readily recognized by the 
fact that urine which is turbid from their presence, becomes perfectly 
clear and transparent when boiled. Further, the addition of acids 
causes the formation of crystals of uric acid, and murexide may be de- 
veloped by the method already indicated. Urate of soda is occasion- 
ally present in the shape of small globular concretions beset with coni- 
cal spikes. These form in the urine while it is yet in the urinary 
cavities, and are liable to cause much irritation, and to lead to the 
development of calculi. They have been especially observed in the 
urine of children suffering from febrile symptoms. 

Other nitrogenous substances found in varying proportions in the 
urine are for the most part closely related chemically to uric acid and 
urea and derived from the same sources; of these xanthin, cystin, 
leucin, and tyrosin are chiefly interesting. 

Xanthin (C 3 H 4 N 4 0 2 ) is a waxy, white, non-crystallizable substance, 
almost insoluble in cold water. When heated with nitric acid it dis- 
solves without evolving gas; and the residue left on evaporation ac- 
quires when heated with caustic potash a beautiful violet-red color. 

Cystin (C 3 H 6 N0 2 S) contains 25.5 per cent, of sulphur. It is closely 
related chemically to taurin, and hence probably furnished by the 
liver. It is a neutral body, insoluble in water, and crystallizes in 
hexagonal plates. It is dissolved by the mineral acids with decompo- 
sition, and by the caustic alkalies without. The best way to obtain 
the characteristic crystals is to dissolve the cystin in a solution of am- 
monia and allow the solution to evaporate. 

Leucin (C 6 H 13 N0 2 ) and tyrosin (C 9 H n 00 3 ). — These are formed under 



URINE IN DISEASE. 



757 



the same conditions and are generally associated together. Pure leucin 
occurs in white crystalline scales, has a fatty feel, and dissolves in 
water. In the impure state, as observed in urine, it often assumes 
the form of roundish concentrically marked yellowish bodies which 
have some resemblance to fat-globules. Tyrosin forms a white, silky, 
glistening mass, consisting of fine needle-like crystals, which are 
grouped in radiating clusters and sometimes in dense globular masses. 
The urine of patients suffering from yellow atrophy of the liver often 
deposits spontaneously a greenish-yellow sediment consisting of crystals 
of tyrosin, and on being evaporated yields numerous crystals of the 
more soluble leucin. 

Coloring Matters. — The normal coloring matters of the urine are de- 
rived from the coloring matter of the blood, and, according to Schunck, 
are two in number. He names them respectively urian and urianin ; 
they are of a dark yellow color and syrupy consistence, have a high 
atomic constitution, and contain nitrogen. Their excess or deficiency 
has little special pathological importance. The pink coloring matter, 
termed purpurin or uro-erythrin, is, however, a pathological product; 
its chemical constitution and source have not been ascertained, but it 
is common in febrile and inflammatory affections and in cases of organic 
disease, especially of the liver, and has a remarkable affinity for uratic 
sediments to which it clings and to which it imparts its special tint. 
Indican, the peculiar body by whose decomposition indigo-blue and 
indigo-red are obtained, has been ascertained by Schunck to be a nor- 
mal constituent of urine. It is to this source that the occasional pres- 
ence of indigo-blue in decomposing and morbid urine appears to be 
due. 

The coloring matter of the bile and the biliary acids are found in 
greater or lesser abundance in the urine in cases of jaundice. The 
coloring matter may, according to its amount, impart merely a yellow- 
ish tint, scarcely or not at all distinguishable from that of normal 
urine, or any variety of shade between this and a deep olive green. 
Bile-stained urine seen by reflected light often looks almost black. 
The presence of biliary pigment in the urine may be readily detected 
by the addition of strong nitric acid which produces, where the fluids 
first come into contact, an evanescent succession of green, blue, violet, 
and red tints. The test may be applied either by placing a few drops 
of urine and a few drops of nitric acid close to one another on a white 
porcelain surface, and then allowing them to come together; or by 
putting a little nitric acid at the bottom of a test-tube, and pouring a 
small quantity of urine carefully on the top of it without allowing them 
to mix. In the former case the play of colors takes place at the line 
of mixture, in the latter in the horizontal plane of contact. Dr. G. 
Harley considers that the presence of the biliary acids in the urine is 
characteristic of jaundice from the retention of bile. For their detec- 
tion he recommends that two drachms of the urine be poured into a 
test-tube with a small fragment of loaf sugar, and that then about half 
a drachm of strong sulphuric acid be slowly added in such a manner 
that the two fluids shall not mix. If biliary acids are present a deep 



758 



DISEASES OF THE GENITO -URINARY ORGANS. 



purple hue will be developed after a few minutes at the plane of con- 
tact between the acid and the urine. 

Odorous Matters. — The peculiar smell of normal urine is due to the 
presence of minute proportions of certain volatile organic acids, which 
need not be specified. This smell is well marked when the urine is 
acid ; but when the urine is alkaline from fixed alkali it acquires a 
sweetish odor instead, and when alkaline from decomposition an am- 
moniacal odor. Diabetic urine has a peculiar sweetish smell. 

Grape or Starch Sugar. Glucose. Dextrose. (C 6 H 12 0 6 ,H 2 0). — A 
trace of this substance is frequently, if not always, present even in 
healthy urine. Occasionally it is found in large quantities under the 
influence of various morbid conditions of the system. Its habitual 
presence in quantity is the essential proof of the presence of the malady 
known as diabetes mellitus. Its ready detection, therefore, is a matter 
of importance. Diabetic urine is usually of high specific gravity, has 
a sweet taste, very rapidly develops torulse, ferments on the addition to 
it of a little yeast, with the disengagement of carbonic acid gas, and (as 
one of the names of its saccharine constituent implies) rotates the plane 
of polarization to the right. Many tests for the presence of sugar, some 
founded on the facts above enumerated, have been devised. One of the 
readiest, though not the most delicate, is that known as Moore's test. 
It consists in boiling a mixture of equal parts of the suspected urine 
and of liquor potassse in a test-tube, when if sugar be present a deep 
reddish-brown color becomes developed. The chief objections to this 
test are that in concentrated urine, and in urine containing albumen or 
blood, a distinct deepening of color also takes place, and that if the re- 
agent contain lead, as it often does when kept in glass bottles, this 
deepening of color becomes in urine containing albumen somewhat 
intense. A far more accurate test is that which has received the name 
of Trommer's test. It depends on the influence which grape sugar 
has in decomposing the salts of copper and throwing down from them 
the insoluble red suboxide. The best mode of applying it is the fol- 
lowing: First prepare Fehling's standard solution as follows: Sul- 
phate of copper, 90J grs.; neutral tartrate of potash, 364 grs.; solution 
of caustic soda (sp. grav. 1.12), 4 fluid ounces; and distilled water 
sufficient to make up exactly 6 fluid ounces. 200 grains of this solution 
are exactly decomposed by a grain of sugar. Fill now a test-tube to 
the depth of f inch with the solution, heat it until it begins to boil, and 
then add a drop or two of the suspected urine. If this contain sugar, 
the mixture after a few seconds suddenly turns of an intense opaque- 
yellow color, and in a short time an abundant yellow or red sediment 
falls to the bottom. If very little sugar be present it will be necessary 
to add more of the urine, but its bulk must not exceed that of the test 
solution employed. After the addition of more urine the fluid must 
have its temperature again raised to boiling-point, and then be allowed 
to stand. If no milkiness be produced as the mixture cools, the urine 
is free from sugar. It is important in using this test that the test solu- 
tion of copper shall not have undergone previous decomposition, and 
also that it shall be used in excess. 

It is often important to ascertain the amount of sugar which diabetic 



URINE IN DISEASE. 



759 



patients pass daily. The estimate can be made in various ways. The 
best method is probably that of Fehling, the simplest, perhaps, for ordi- 
nary clinical purposes that of Dr. W. Roberts. Dr. Roberts's method: 
If saccharine urine be made to undergo fermentation, its sugar is con- 
verted into carbonic acid, which escapes, and alcohol, which is of lower 
density than water, and remains ; and hence the density of the urine 
itself becomes considerably diminished. Dr. Roberts finds that every 
degree by which the specific gravity of the urine becomes thus reduced 
represents one grain of sugar per ounce. And in order to ascertain the 
quantity of sugar voided in twenty-four hours, he recommends: first, 
that the total urine for that time be collected and mixed ; second, that 
of this four ounces be placed in an incompletely stoppered 12 oz. bottle, 
together with a lump of German yeast about as large as a cobnut or 
small walnut; third, that at the end of twenty-four hours (by which 
time, if the bottle has been in a warm place, fermentation will have 
been fully completed) the clear urine be decanted into a wine glass and 
its specific gravity taken; and, fourth, that in order to make a fair 
comparison, about four ounces of the same urine be set apart at the same 
time as the other, without ferment, in a close-stoppered 4 oz. bottle, and 
be placed under the same external conditions and decanted at the same 
moment. The two specimens should now be set aside in a cool place 
for an hour or two in order that they may acquire exactly the same 
temperature; and then their specific gravities should be carefully taken. 
The number of degrees by which the density of the one urine exceeds 
that of the other represents the number of grains of sugar which are 
contained in each ounce of the day's urine. 

The principle of Fehling's test is to determine how much of the 
total bulk of urine passed in twenty-four hours is required to precipi- 
tate the whole of the copper contained in a known bulk of Fehling's 
test solution, of which, as before pointed out, 200 grains are exactly 
decomposed by a grain of sugar. A carefully measured quantity of 
this fluid, diluted with about four times its bulk of water, should be 
placed in a large china dish and heated to nearly boiling-point; and a 
measured quantity of urine, diluted with ten or tw r enty times its vol- 
ume of water, so as to reduce the percentage of sugar in the mixture to 
between one-half and one per cent., should be placed in a burette. 
Then the diluted urine should be cautiously added to the prepared 
test solution until the w T hole of the copper in it has been precipitated 
in the form of a red powder. The quantity of urine which has been 
employed in the process can now be read off the scale of the burette ; 
and by an easy calculation the total amount of sugar passed during the 
twenty-four hours determined. It is, of course, necessary on the one 
hand to effect the precipitation of the whole of the copper ; and on the 
other to add no more urine than is absolutely necessary for the pur- 
pose. The urine should therefore be added in drops towards the end 
of the process and the effect carefully watched. It may continue to be 
thus added so long as it produces a light yellow cloud on the surface 
of the fluid. But when the formation of this cloud ceases to be obvious, 
it is essential to remove the flame from underneath the dish and to 
allow the precipitate to fall. As soon as the originally blue super- 



760 DISEASES OF THE GENITO -URINARY ORGANS. 



natant fluid is quite colorless, the experiment is completed. But so 
long as any tinge of blue remains the addition of urine to the boiling 
fluid must be continued. 

Salts. — The relative quantities of the salts which are contained in 
urine have little apparent relation to morbid processes going on in the 
system. The chlorides are sometimes greatly diminished in pneu- 
monia ; and the phosphates are increased in acute inflammation of the 
brain and in some functional affections of the same organ, and are said 
to be diminished in diabetes. The chief pathological importance of 
the salts resides in the fact that they very frequently indeed form sedi- 
ments and accrete into calculi. The most important of them are as 
follows : 

1. Amorphous Phosphate of Lime (Ca 3 2P0 4 ). — This precipitates 
only in urine which is alkaline; it forms an amorphous sediment like 
that of the urates, but does not carry with it the coloring matter of 
the urine. The application of heat increases the precipitate, and not 
unfrequently causes it. It is dissolved, however, on the addition of 
a drop or two of nitric acid. It often forms an iridescent pellicle on 
the surface. 

2. Crystallized Phosphate (CaH,P0 4 ). — Dr. Roberts regards this 
sediment, which is rare, as an accompaniment of grave disorders. It 
occurs in rods and needles, which are often arranged in tufts and stars. 

3. Ammoniaco-Magnesian Phosphate (H 4 NMgP0 4 ). — This always 
falls in ammoniacal urine. It is occasionally present in slightly acid 
urine; but is much more frequent in that which is alkaline, and is 
then often associated with the amorphous phosphate. It is occasion- 
ally observed as an habitual constituent of freshly-voided urine. Its 
ordinary crystalline form is that of a triangular prism with bevelled 
ends. But this form is liable to numerous modifications. 

4. Oxalate of Lime (CaC 2 0 4 ,2H 2 0). — The presence of oxalic acid in 
the urine is not surprising considering that it, with carbonic acid, is 
one of those ultimate substances into which organic matters become 
reduced. Its presence in the urine is doubtless in the majority of 
cases due to such reduction, but sometimes it depends on the ingestion 
of articles of diet, such as rhubarb, which contain it. It occurs in the 
urine in combination with lime, usually forming small oblique octahe- 
dral crystals, and occasionally dumb-bell-shaped bodies. The crystals 
generally fall, entangled with the mucus, and when large may be seen 
as shining points with the naked eye. Their occasional presence is a 
matter of little importance ; but when they are of habitual occurrence 
there is reason to fear the formation of oxalate of lime calculi, and 
there is often some obvious impairment of health. Oxalate of lime 
rarely occurs in alkaline or neutral urine. Its crystals are readily 
soluble in the mineral acids. 

5. Carbonate of Lime (CaC0 3 ). — This is sometimes deposited as 
an amorphous powder in alkaline urine, and is occasionally found in 
the form of minute rounded calculi, with a well-marked concentric 
structure. 

Albumen. — This substance is never met with in healthy urine, and 
its presence, in any quantity at least, is one of the most significant 



URINE IN DISEASE. 



761 



indications of renal disease. It is observed under various circum- 
stances. Whenever there is suppuration in connection with any of the 
urinary organs, and pus is consequently contained in the urine, albumen 
is present in small proportion. In many specific fevers and other 
febrile disorders, albuminuria is liable to occur. In congestion of the 
kidneys, due to heart disease, bronchitis, or obstruction of the renal 
veins or arteries, again, albuminuria is frequently observed. The 
most important causes of this condition, however, are inflammation of 
the kidney, and those various chronic lesions which are usually com- 
prehended in the term " chronic Bright's disease." 

The presence of albumen in the urine may always be recognized by 
its coagulation under the influence of heat or nitric acid. To apply 
the former test, a portion of the urine should be placed in a test-tube 
and then boiled by means of a spirit-lamp. If the urine contain al- 
bumen, opaque flakes form in it, which render it more or less turbid, 
and gradually fall to the bottom of the glass. If there be much 
albumen present, turbidity appears before the urine begins to boil ; if 
there be only a trace, actual ebullition is essential to its production. 
In the employment of heat one or two precautions are necessary to be 
observed. In the first place, albumen is not precipitated if the urine 
is alkaline, and hence alkaline urine should be first acidified by the 
addition of a few drops of acetic acid. In the second place, in slightly 
alkaline or neutral urine, heat is apt to throw down a deposit of amor- 
phous phosphates. These, however, dissolve on the addition of an 
acid. The nitric acid test may be employed as follows : A test-tube 
should be partially filled with urine, and then strong nitric acid should 
be slowly poured down the side of the tube and allowed to form a 
layer one-fourth or half an inch deep at the bottom. If albumen be 
present, a white cloud soon appears in the layer of urine which is in 
contact with the acid. The fallacies which may arise in connection 
with this test are : first, that urine of patients who are taking cubebs or 
copaiba is apt to become slightly turbid under the influence of nitric 
acid ; second, that in concentrated urines and in those which are rich in 
urea, some deposition of urates or of nitrate of urea may occur; and, 
third, that the addition of a very minute proportion of nitric acid does 
not always precipitate the albumen, and the addition of an excessive 
quantity may prevent its precipitation altogether. [It will be found 
more satisfactory in practice to pursue a slightly different plan in ap- 
plying this test. The suspected urine should be allowed to trickle 
slowly from a pipette down the sides of a test-tube containing from 
half a drachm to a drachm of the acid. If this is done carefully, so as 
to avoid the intermingling of the two liquids, it will very rarely hap- 
pen that even small quantities of albumen will escape detection, and 
there will generally be no difficulty in distinguishing a precipitate due 
to its presence from one composed of the urates. The former is de- 
posited just where the urine and acid come in contact, and has borders 
above and below as sharply defined as if cut with a knife ; whereas, on 
the other hand, the latter occupies a position a line or two above this, 
and while its lower border is well defined, it has a tendency to be 
drawn out in shreds above. This test will sometimes show the pres- 



762 DISEASES OF THE GENITO -URINARY ORGANS. 



ence of both of these substances in the same urine, in which case there 
will be two precipitates, each having its own peculiar characteristics.] 
A saturated solution of picric acid also precipitates albumen. The 
relative quantity of albumen present in any specimen of urine may be 
roughly but conveniently estimated by boiling the whole of the slightly 
acidified portion placed in a test-tube, and then allowing the coagu- 
lated flakes to subside. 

Blood may be found in the urine in various proportions and in dif- 
ferent conditions, and may be furnished by any part of the urinary 
tract, from the kidneys downwards. The greater the quantity of blood 
passed, and the nearer its source to the external urethral orifice, the 
less will it deviate from the normal condition of blood, and the more 
readily will it be recognized. Its presence may be due to inflamma- 
tion or carcinomatous and other like growths, or concretions, or para- 
sites, situated either in the pelvis of the kidney or in some other part 
of the excretory apparatus, namely, the ureter, bladder, or urethra. 
When derived from the kidney-substance, it is the result either of in- 
flammation, congestion, or the presence of adventitious growths, or of 
injury. Hematuria occasionally also follows the use of cantharides or 
other drugs, and is frequently met with not only in those febrile dis- 
orders which are attended with albuminuria, but in purpura, scurvy, 
and other affections which assume a petechial character. When much 
blood is effused, it occasionally coagulates in the bladder; and not un- 
frequently coagulates more or less imperfectly in the chamber-pot. 
When present in smaller quantities and diffused uniformly through- 
out the urine, it imparts to it a slight degree of opacity or turbidity, 
and a color which may resemble that of a dilute solution of the com- 
pound infusion of roses, or be of a peculiar smoky or dirty reddish 
brown, varying in depth and distinctness according to the quantity of 
blood present. On standing, such urine for the most part deposits a 
grumous or coffee-ground-like sediment. The presence of blood is 
additionally proved by the detection of albumen in the urine by the 
usual tests, and by submitting a specimen to microscopic examination, 
when almost always blood-corpuscles will be readily detected, some- 
times disk-like, sometimes globular, sometimes crenate, occasionally re- 
taining their coloring matter, but usually colorless, having imparted 
their pigment to the fluid in which they float. In a peculiar affection, 
shortly to be described — paroxysmal hematuria — although the urine 
contains abundance of blood, distinct blood-corpuscles are rarely de- 
tected. And occasionally, as Dr. Mahomed has shown to be especially 
the case at a certain period in scarlet fever, prior to the occurrence of 
albuminuria and anasarca, the coloring matter of the blood transudes 
into the urine, where it may be detected either by the spectroscope or 
the guaiacum test. The latter may be applied as follows : Place a 
drop or two of the urine in a small test-tube, add one drop of tincture 
of guaiacum and a few drops of ozonized ether ; agitate, and then 
allow the ether to collect at the top. If blood coloring matter be 
present, the ether acquires a blue color, leaving the urine below color- 
less. No saliva must be mingled with the urine, and the patient must 
not be taking any salt of iodine. (Mahomed, Med.-Chir. Tra7is. } vOl. lvii.) 



URINE IN DISEASE. 



763 



Casts. — In almost all cases in winch albuminuria or hematuria is 
clue to morbid conditions of the secreting structure of the kidneys, and 
occasionally in specimens of urine which seem to be free from both 
blood and albumen, microscopic cylinders which have been moulded in 
the urinary tubules, and are therefore termed casts of these tubules, 
may be detected with the aid of the microscope. Of these several 
varieties may be distinguished. The following enumeration comprises 
the more common of them. 1. Epithelial casts. These consist of 
renal epithelium. Occasionally the epithelium differs little from the 
normal epithelium of the tubules. More commonly the cells are 
granular and degenerating. In other cases the casts are formed mainly 
if not entirely of new-formed cells which then assume an embryonic 
character, and have therefore more or less resemblance to pus-cells. 
2. Hyaline casts. These, when presenting their typical characters, are 
homogeneous, transparent, glassy-looking cylinders, with a tendency 
to fracture transversely. There is some doubt whether they usually 
consist of coagulated fibrin or of colloid matter ; and it is said that 
occasionally those furnished by lardaceous kidneys are themselves lar- 
daceous, and exhibit the characteristic reaction with iodine. Hyaline 
casts, however, present many varieties; they differ greatly in their 
diameter, and not unfrequently epithelial or embryonic cells, or granu- 
lar particles, are entangled in them. They differ, too, in their refrac- 
tile power, and in their visibility. 3. Granular casts. These vary in 
size, but are often of considerable bulk ; and are studded more or less 
thickly and more or less irregularly with granular matter, which often 
renders them perfectly opaque. They are probably, at any rate, in the 
greater number of cases, colloid or fibrinous casts, studded with the 
debris of degenerating cells. Indeed, distinct compound granule-cells 
can often be detected in them. 4. Fatty casts. These are characterized 
by the presence in them of distinct fatty globules, which are sometimes 
of considerable size. Fatty globules may be observed in either 
epithelial, hyaline, or granular casts. The fatty matter is not pure 
olein, but seems generally to be a mixture of this with cholesterin 
and some albuminous matter. 5. Blood casts. Generally in renal 
hematuria the casts consist, in a greater or less degree, of coagulated 
fibrin entangling the corpuscular elements of the blood. The corpus- 
cles may be more or less obvious ; the casts may be pigmented in 
various degrees ; and both pigment and blood-corpuscles may be 
blended in greater or less proportion with the epithelial or granular 
forms of casts. 

It must be added that crystals of oxalate of lime and of uric acid are 
not unfrequently discovered imbedded in renal casts ; and, further, that 
epithelial casts generally indicate acute disease, large hyaline casts and 
fatty casts chronic and degenerative disease ; while small hyaline casts, 
granular casts, and blood casts are of little special significance. 

Mucus and Pus. — In normal urine but little mucus is present ; it 
falls as a scarcely perceptible cloud, and contains perhaps traces of 
vesical and urethral epithelium, and in the female squamous vaginal 
epithelium. When, however, there is any inflammatory condition of 
the mucous lining of the urinary channels or reservoirs, the mucous 



764 



DISEASES OF THE G ENITO -URINARY ORGANS. 



secretion becomes increased, cells are discharged in excess, and imma- 
ture forms, in other words, cells identical with those of pus, are pro- 
duced in greater or less abundance. The transition between mucus and 
pus is almost imperceptible. The discharge, if sufficiently abundant, 
renders the urine turbid and slightly albuminous; and a sediment, 
which may present a greenish-yellow hue, presently forms. If the 
urine retain its acid reaction, this sediment is readily miscible with the 
urine; if, however, it become, as it is very apt to become, alkaline, then 
the sediment becomes tenacious and ropy. The secretion of inflamma- 
tory mucus has a remarkable influence in promoting the decomposition 
of urea; the urine, therefore, in these cases has a great tendency to be- 
come ammoniacal, to deposit earthy phosphates, and to assume irritant 
properties. The abnormal secretions here described are most commonly 
furnished by the inflamed mucous membrane of the pelvis of the kid- 
ney, or by that of the bladder. But it must not be forgotten that pure 
pus may be poured into the urinary passages, either from renal abscesses, 
or in consequence of the rupture of some neighboring abscess into them. 
Pus can be readily recognized by its microscopic characters. 

Fat, excepting in the form which has been already described in con- 
nection with renal casts, is of rare occurrence in the urine. The pres- 
ence of fluid fat in the form of globules is said to have been occasionally 
observed. Crystals of cholesterin also have been met with. In a case 
of Dr. Murchison's, the cholesterin was traced to a pyonephritic cyst. 
The most interesting cases of fatty urine, however, are those in which 
this fluid presents a milky or chylous character, due to the presence in 
it of fatty matter in a molecular or amorphous condition. In these 
cases the urine contains albumen, fibrin, and leucocytes, in addition to 
fat ; it hence tends to spontaneous coagulation ; it coagulates with heat ; 
a creamy layer rises to the top when it is allowed to stand ; and it may 
be rendered clear, and the fat be separated, by agitating it with ether. 

Morbid Growths. — Tubercle, carcinoma, and other growths are apt 
to arise in various parts of the urinary organs ; and it might hence be 
supposed that their characteristic elements should be occasionally dis- 
covered in the urine. It must be exceedingly rare, however, for such 
specific indications to be met with in connection with disease of the 
kidneys. In villous growths of the mucous membrane of the bladder, 
fragments may, no doubt, be detached and occasionally discovered in 
the urine. It must be borne in mind, however, that the cells of the 
vesical epithelium have a great resemblance to typical cancer cells, and 
may be easily mistaken for them. 

Spermatozoa are occasionally present in the urine, and may be readily 
recognized in the sediment. Their presence is of little clinical impor- 
tance, unless other symptoms combine to indicate the existence of ab- 
normal spermatorrhoea. 

Animal and Vegetable Organisms. — Hydatids are occasionally devel- 
oped in the urinary organs, or hydatid cysts may open into them. The 
urine under such circumstances may present actual hydatids or echino- 
cocci, or fragments of one or the other. The peculiar laminated char- 
acter of the hydatid membrane, and the hooklets of echinococci, are, 
under the microscope, quite unmistakable objects. In the endemic 



URINARY CONCRETIONS. 



765 



hematuria of Egypt, the Cape, Natal, and other parts of Africa, the 
symptoms are due to the presence in the veins of the pelvis of the kid- 
ney, ureter, and bladder, of a small unisexual parasite, termed the 
Bilharzia hcematobia. The presence of this affection may be recognized 
by the discovery in the urine of the ova and free embryos of the 
parasite. 

Sarcina? have been observed in the urine when passed- from the 
bladder. Lastly, bacteria and penicillium form rapidly in urine which 
is undergoing decomposition, and the yeast-plant in that of diabetic 
patients. 

Concretions. — These may occur in the form of a fine sand, in which 
case they are termed gravel, or in masses varying from the size of a 
tare or mustard seed upwards, when they are known as calculi. Calculi 
and gravel may consist of any of the solid matters which have been 
described as occasionally separating from the urine, either separately 
or in combination. The more important of them are the uric acid, 
the uratic, the cystin, the xanthin, the oxalate of lime, the phosphatic, 
and the carbonatic. 

1. Uric acid concretions are the most common. They constitute 
five-sixths of the total number of calculi which are formed in the kid- 
ney, and wholly or in part the great majority of those observed in the 
bladder. As gravel, uric acid forms angular groups of crystals ; as 
calculi, it constitutes in the kidney small, round, or oblate-spheroidal, 
often tuberculated bodies, which vary in color from pale fawn to a deep 
reddish-brown. In the bladder they attain a large size. They are 
hard, have a specific gravity of about 1.5, are formed in concentric 
laminae, and may be recognized by the tests for uric acid. 

2. Uratic calculi are rare, and occur mostly in children under puberty. 
They are small, slate or clay-colored on the surface, smooth or granu- 
lar, formed in thin ill-marked laminae, and very friable. They are 
readily soluble in boiling water, and respond to the other tests for 
urates. 

3. Cystin calculi are very rare. When pure they are yellow, trans- 
parent, wax-like, and soft; the outer surface is somewhat crystalline, 
the sectional surface radiated. When long exposed to daylight they 
tend to assume a pale green color. The circumstances wdiich determine 
their formation are not known, but the tendency to them seems to run 
in families. Cystin may be recognized by the form of its crystals. 

4. Xanthin calculi are also exceedingly rare, and have a close resem- 
blance to those of uric acid. 

5. Oxalate of lime calculi are next in frequency to those of uric acid. 
They frequently form in the kidney and are then generally small, 
smooth, and of a dark color. In the kidney, however, and more par- 
ticularly in the bladder, they often attain a large size, and are then 
usually tuberculated or spiny on the surface, constituting what are 
called mulberry calculi. These, on section, are found to be laminated, 
the successive laminae presenting a wavy or crenated character. Oxa- 
late of lime calculi are exceedingly hard, and, though generally dark, 
vary much in color. When very pure they are occasionally milk- 



766 DISEASES OF THE GENITO -URINARY ORGANS. 



white. Oxalate of lime is dissolved by mineral acids, and precipitated 
from the solution by an excess of ammonia. 

6. Calculi of amorphous phosphate of lime, or bone-earth, and of 
ammoniaco-magnesian phosphate, are both exceedingly rare. The fusi- 
ble calculus, or calculus composed of a mixture of these salts, is, on the 
other hand, very common. The precipitate constituting this calculus 
commonly takes place in ammoniacal urine, and hence in the renal 
pelvis and in the bladder of patients who have chronic inflammation of 
these parts ; and hence, further, it is specially apt to take place when 
calculi of other composition are producing irritation. Phosphatic matter, 
indeed, rarely forms the nucleus of a calculus, but it tends to accu- 
mulate on the surface of other calculi, and, when once it begins to col- 
lect there, is rarely succeeded by any other form of deposit. Phos- 
phatic calculi are light, loose-textured, imperfectly laminated or 
amorphous, and white, gray, or dark-yellow. 

7. Carbonate of lime very rarely forms urinary calculi in the human 
being. It commonly, however, takes part in the formation of the 
minute, dark-colored, laminated concretions (sometimes called corpora 
amylacea) which are met with in the prostate. Dr. Roberts quotes a 
case of Dr. Haldane's in which it was proved by post-mortem exami- 
nation that carbonate of lime calculi, presenting similar characters, 
may be formed in the pelvis of the kidney and passed with the urine. 

Calculi formed of blood, albumen, or fat, have been occasionally 
met with. 

Urinary concretions always contain more or less organic matter com- 
bined with their main ingredients, and in a large number of cases the 
nucleus has a different chemical constitution from the layers subse- 
quently formed. Further, any foreign body, whencesoever derived, 
may form the nucleus around which urinary deposits accrete. 

The Specific Consequences of the Retention of Urea and other such 
matters in the Blood. 

The presence of structural disease in the kidneys, involving both 
organs uniformly, is almost invariably attended with one important 
consequence, namely, the prevention, in a greater or less degree, of the 
elimination of urea, uric acid, and other products of the retrograde 
metamorphosis of nitrogenous matters, and their consequent retention 
in the blood and in the fluids which bathe the tissues. Following 
upon this retention, and in part dependent on it, but in part, no doubt, 
dependent on the constant loss of albumen which commonly attends 
diseases of the kidneys, the quality of the blood undergoes deteriora- 
tion ; it grows watery, poor in albumen and in corpuscles, and at the 
same time fibrin becomes relatively increased. The patient gets 
anaemic and suffers consequently from many of those morbid conditions 
which characterize anaemia. But, in addition to these phenomena, 
others of great gravity, and in the aggregate special to renal disease, 
sooner or later supervene. These have been attributed simply to the re- 
tention of urea, but the experimental introduction of urea into the blood 
seems to show that this substance has little or no poisonous property. 



CONSEQUENCES OF THE RETENTION OF UREA. 767 



It can scarcely be denied, however, that the phenomena in question are 
really referable to the retention, either of urea or of some of the less 
oxidized matters which accompany it, namely, uric acid, kreatin, 
kreatinin, and the like. Frerichs maintains that some of them are 
due to the conversion of urea in the blood into carbonate of ammonia. 
The chief morbid phenomena here referred to are: thickening and 
contraction of the smaller bloodvessels; hypertrophy of the heart; 
anasarca and other dropsical effusions; local congestions and haemor- 
rhages ; inflammation of different organs, mainly those of the thorax ; 
and, lastly, various functional diseases of the digestive and other 
organs, but, above all, of the central nervous system. 

Thickening and Contraction of the Smaller Bloodvessels. — Dr. George 
Johnson showed some years since that in cases of chronic renal disease 
the walls of the minute arteries, both in the kidneys themselves and 
generally throughout the system, became extremely thick, and at the 
same time their channels greatly contracted. He attributed the thick- 
ening to hypertrophy of the muscular coat and the narrowing to the 
tonic contraction of this coat, and regarded the combined phenomena as 
an effort of nature to oppose the transmission of poisoned blood to the 
tissues. The thickening of the arterial tunics and the contraction of 
the arterial channels in chronic renal disease are now established facts. 
It has, however, lately been maintained, more particularly by Sir W. 
Gull and Dr. Sutton, that the thickening is the result not of muscular 
hypertrophy, but of a " hyaline-fibroid " conversion ; that it is in fact 
a change not unlike that which occurs in cirrhosis of the liver and 
sclerosis of other organs — a change which in a sense may be regarded 
as degenerative. In these latter views, so far as we have stated them, 
we are disposed to concur. 

Hypertrophy of the heart, independent of all valvular affection, has 
long been recognized as one of the most obvious attendants on chronic 
kidney disease. The hypertrophy is general, and associated with more 
or less dilatation; but the changes are, perhaps, more obvious in the 
left ventricle than elsewhere. Dr. Quain has shown that the thicken- 
ing of the walls is due in some degree to increase of the connective tis- 
sue, in other words to a kind of sclerosis ; there is no doubt, however, 
that it is mainly dependent on muscular overgrowth, and that the stim- 
ulus to this overgrowth consists in some obstacle which the heart's 
action has to overcome. But since the valves and larger arteries are 
all, for the most part, healthy, this obstacle is not presented by them. 
There are obvious reasons why the veins must be considered to be in- 
operative in the matter. We are compelled, therefore, to look to the 
small arteries and capillaries. And that the obstruction really does 
reside in these vessels is clearly shown by the high tension which by 
sphygmographic observation has been proved to prevail throughout 
the arterial system in such cases. It was formerly believed that the 
obstruction was caused by some abnormal attraction between the capil- 
lary bloodvessels or the tissues outside them and the morbid blood. 
It is, however, doubtless due to the contraction of the channels of the 
capillary arteries. Dr. Sibson has shown that in these cases the actions 



768 DISEASES OF THE GENITO -URINARY ORGANS. 



of the two sides of the heart are generally not quite synchronous, and 
that hence the heart's sounds become as a rule reduplicated. 

Anasarca and other Dropsical Effusions. — Kidney disease is one of 
the most frequent causes of general anasarca. This condition very 
often reveals itself first in the regions in which the connective tissue is 
lax, as in the scrotum, eyelids, and conjunctivae, and is often recognized 
in the face before it appears in the lower extremities. There is gener- 
ally neither lividity nor dilatation of veins; but the swollen surface 
presents an anaemic, wax-like character. Its cause is somewhat obscure. 
It is evidently not passive, for there is neither venous obstruction nor 
venous hyperaemia; nor again is there any obvious impediment to the 
due action of the lymphatic vessels. It must then be due either to 
some peculiar tendency in the serum of the blood to transude through 
the capillary vessels, or to the sweating of this fluid through the walls 
of the smaller arteries in consequence of the heightened pressure which 
the blood within them exerts. In reference to this question it should 
be mentioned that Dr. Mahomed has recently shown that in scarlet 
fever there is a stage, preceding the occurrence of anasarca and even 
the appearance of blood or albumen in the urine, during which high 
arterial tension prevails, as demonstrated by the resistance of the pulse 
to pressure and the form of the pulse-trace, and during which also the 
coloring matter of the blood may sometimes be recognized in the urine. 
The anasarca is not merely subcutaneous, but may involve the lax tis- 
sues of the larynx, the pulmonary tissue, and other parts of the system ; 
and is commonly associated with effusion into the several serous cavities. 
It is usually attended with a dry skin and considerable diminution of 
urine ; to which circumstances and to coexistent anaemia it is probable 
that in some cases the presence of dropsy is in part attributable. 

Congestions and hemorrhages are among the consequences of kidney 
diseases. The most important of them are: effusion into the substance 
of the brain, causing apoplectic symptoms; effusion into the choroid 
and retinal coats of the eye, attended with aching across the temples 
and at the occiput, and leading to atrophic changes and more or less 
impairment of vision; and effusion into the lung-substance, producing 
the condition known as pulmonary apoplexy. The causes of these 
haemorrhages are, in part, the same as induce anasarca ; but in chronic 
renal disease there is a marked tendency to atheromatous and fibroid 
degeneration of the arteries, and hence effusions of blood may in some 
cases be due to rupture of diseased and enfeebled vessels. 

Inflammatory affections are of frequent occurrence. The most com- 
mon and serious of these are inflammations of the pericardium and 
pleurae, of the larynx, bronchial tubes, and lungs. But inflammation 
may also affect the abdominal viscera ; and, indeed, no part is wholly 
exempt from liability to it. When anasarca is present it is of course 
common for an erythematous blush to make its appearance somewhere 
or other on the surface. 

The functional consequences of renal disease are very numerous. 
Dyspepsia, nausea, vomiting, and diarrhoea, the former three especially, 
are common phenomena, even when no local lesion of the organs in- 
volved can be traced. Palpitation and dyspnoea, or hurried respiration, 



PYELITIS. 



769 



are not unfrequently observed in cases in which the heart and lungs 
present little if any sign of disease. Drowsiness, headache, irritability, 
hypochondriasis, and even more or less maniacal disturbance and wake- 
fulness are all of them liable to arise. But the most serious of the 
functional disturbances of the nervous system are coma and convul- 
sions. These are generally preceded by some of the less grave mental 
phenomena above enumerated. The convulsions occur in paroxysms 
which almost exactly simulate those of true epilepsy, and, associated 
with coma, often succeed one another at short intervals until they ter- 
minate in death. 

The Non-specific Morbid Phenomena which Attend on and Characterize 
Lesions of the Kidneys. 

Other symptoms wmich attend and indicate the presence of renal dis- 
ease are totally independent of impairment or suppression of the proper 
functions of the kidney. These are symptoms which are determined 
by the locality of the diseased organ, and such others as are referable 
to it as a focus of inflammation or other morbid processes. Among 
the former of these are comprised pain and tenderness, tumor, and the 
results of pressure ; amongst the latter the general symptoms of inflam- 
matory fever when the organ is inflamed, the cachexia which follows 
the development of malignant disease there, and the anaemia which 
results from the continued escape of blood, or of that important ele- 
ment of the blood — albumen. 



PYELITIS. 

Causation. — Inflammation of the lining membrane of the kidney 
may be excited in various ways. It rarely results from exposure to 
cold, or arises in association with ordinary nephritis. It may, however, 
be induced by the use of special medicinal irritants, such as cantharides 
and turpentine, which probably induce at the same time a similar con- 
dition in the lining membrane of the bladder and in the secreting 
tissues of the kidney. But the most frequent cause of pyelitis is direct 
irritation of the mucous surface, due either to the constant fretting of a 
renal calculus or to the influence of irritating discharges or decomposing 
urine, as occurs in cases of long-continued obstruction of the urinary 
passages. Independently of the latter condition, vesical inflammation 
is apt to creep by continuity along fhe ureter to the pelvis and thence 
to the infundibula and calyces. 

Morbid Anatomy. — The anatomical signs of pyelitis are congestion, 
thickening and softening of the mucous membrane, with sometimes 
submucous haemorrhage ; and the discharge from its free surface of 
mucus comprising shed epithelium and pus-like corpuscles, and in 
some cases of blood. If the affection be persistent or intense, other 
phenomena probably supervene ; the thickened mucous membrane may 

49 



770 



DISEASES OF THE GENITO -URINARY ORGANS. 



become opaque, yellow, or gray, and lose its vivid redness ; suppura- 
tion may be established, false membranes may be developed, or ulcera- 
tion may take place. Further, the effect of the unhealthy products 
of the mucous surface upon the urine is to render it ammoniacal and 
to promote the precipitation of earthy phosphates, which are then apt 
to concrete in more or less abundance on the inflamed surface. Other 
changes which are liable to ensue in the course of pyelitis depend on 
impediment to the escape of urine from the inflamed cavity ; they are 
dilation of the pelvis, infundibula, and calyces, and atrophy of the se- 
creting structure. Again, inflammation may extend by continuity fiom 
the pelvis to the renal substance, and abscesses may consequently form 
in it. Suppurative pyelitis, especially if it be confined to one kidney, 
and the pus can escape freely from it per vias naturales, may continue 
for years with little or no additional mischief ; and even when com- 
plete obstruction of the ureter has arisen it is possible that the whole 
affair may become quiescent ; the expanded, atrophied, and indurated 
renal substance losing all its functional power, and the pus in the di- 
lated calyces and rest of the renal cavity drying up into a creamy, 
putty-like, or mortary substance. In other cases, however, and this 
whether the ureter be wholly or only in part obstructed, the renal 
abscess takes another course. It behaves, in fact, as any other abscess 
originating in the vicinity might behave. It transgresses its original 
renal limits, and then forms sinuses which enlarge and burrow in va- 
rious directions. Occasionally they perforate the diaphragm, and open 
into the pleura or lung ; sometimes they point in the loins ; sometimes 
rupture into the peritoneum ; sometimes open directly into the adjoin- 
ing colon ; sometimes, descending along the psoas muscle, point under 
Poupart's ligament, or gravitate towards the lesser trochanter ; some- 
times pass into the pelvis, and communicate there with the rectum, 
bladder, or vagina. 

Symptoms and Progress. — The special symptoms of pyelitis comprise 
pain and tenderness in the loins, irritability of the bladder, and modi- 
fication in the quality of the urine. The pain in the loins is apt to 
shoot thence into the abdomen, and especially downwards to the labium 
or testis of the corresponding side and along the inner aspect of the 
thigh. The tenderness reveals itself, and the pain is aggravated, 
during movement of the body, but especially if the affected side of 
the abdomen be firmly grasped, or the thigh be flexed by its own mus- 
cular efforts on the abdomen, in which case the enlarging bulk of the 
psoas muscle presses on the inflamed organ. There is more or less 
irritability of the bladder, with pain and scalding in the act of mictu- 
rition. The water is more or less turbid from the presence of mucus, 
or it contains pus or blood, or both, and is usually acid ; after a time, 
however, it is apt to become ammoniacal from the decomposition of 
urea, and then to deposit amorphous and crystalline phosphates. It 
need scarcely be added that it does not necessarily contain renal casts, 
and that the presence of these indicates simultaneous involvement of 
the secreting structure of the kidney. Sometimes the discharge of pus 
is profuse ; and both in this and in other cases the products of the in- 
flamed surface are not unfrequently passed intermittently — temporary 



PYELITIS. 



771 



obstructions probably taking place in the ureter, in consequence of 
which the inflammatory products accumulate in the renal cavity with 
aggravation of local symptoms, and the urine becomes comparatively 
clear and healthy. The general symptoms are mainly those of inflam- 
matory fever. This assumes for the most part a remittent character, 
and is often attended with rigors. Vomiting and diarrhoea are not 
unfrequent. 

The symptoms, progress, and results of pyelitis differ widely in dif- 
ferent cases. If one kidney only be affected the disease may continue 
indefinitely without any very serious impairment of the patient's 
health ; the organ may, indeed, become totally disorganized with little 
or no obvious detriment to health; but on the other hand the forma- 
tion of an abscess is even in this case attended with many risks, and 
its continuance may cause death either by slow exhaustion, aggravated 
probably by the presence of hectic fever, or of lardaceous degeneration, 
or by the supervention of some intercurrent affection. When, how- 
ever, both kidneys are diseased, as may occur in calculous pyelitis, and 
as nearly always takes place when the pyelitis is secondary to cystitis, 
the symptoms which the patient presents are necessarily greatly aggra- 
vated, and the probability of an early fatal issue is much increased. 
For in addition to the risks which attend disease confined to one kid- 
ney, we have now the additional risks which arise from the liability to 
more or less complete retention of urea in the blood, and those which 
flow from the comparatively wide extent of the inflamed area. The 
patient passes into a typhoid condition, attended with muttering de- 
lirium, and not unfrequently complicated with epileptiform convul- 
sions and coma. 

Accumulation of pus in the kidney may be suspected when the dis- 
charge of pus with the urine ceases suddenly and continues in abey- 
ance ; it may also be suspected when, following upon symptoms indi- 
cative of pyelitis, rigors take place and at the same time throbbing pain 
and tenderness manifest themselves in the region of one of the kidneys. 
The diagnosis of an abscess under either of these circumstances must be 
based partly on the persistence of the above conditions, partly on the 
presence of increasing fulness in the same neighborhood. If the ab- 
scess point externally all doubt will be speedily removed. Under 
other circumstances many difficulties will necessarily present themselves. 

Treatment. — In the treatment of pyelitis it is of primary importance 
to ascertain its cause, and to remove or obviate it if possible. Thus 
when it depends on retention of urine, following stricture, enlarged 
prostate, or paralysis of the bladder, our aim must be (if not to cure 
these lesions) at all events to empty the bladder periodically and if 
necessary to wash it out with antiseptic solutions ; when it depends on 
the presence of renal or vesical calculi we must endeavor to remove 
these, or, failing this, to maintain rest ; if the inflammation depend on, 
or be associated with, gout, scrofula, or any other special cachexia, it 
will probably be well to modify our treatment accordingly. 

When pyelitis is acute and the local symptoms are severe it may be 
necessary to remove blood from the loins either by cupping or leeches, 
and to use hot fomentations, poultices, ice-bags or equivalent applica- 



772 DISEASES OF THE GENITO -URINARY ORGANS. 



tions. Counter-irritants too, always excepting cantharides, may be em- 
ployed. The administration of opium in doses sufficiently large and 
sufficiently often repeated to relieve pain and procure ease and rest, is 
of essential importance. Moderate purging, voluminous bland clysters, 
and hot baths are also valuable aids. When the disease assumes a 
more chronic character local measures become less important, and opi- 
ates also are comparatively little needed. It may, however, still be 
desirable to give these latter in small doses, or to administer some 
other form of sedative or anodyne, such as hyoscyamus, belladonna, or 
chloral hydrate. Tonics, however, and nutritious diet become now 
our most valuable remedial agents ; among the former quinine and the 
other vegetable bitters and iron, especially the perchloride, and cod- 
liver oil must be especially enumerated. If the urine be alkaline the 
nitro- muriatic or some other mineral acid may be beneficially combined 
with the other remedies. Buchu, pareira brava, and uva ursi, so much 
appreciated by surgeons in the treatment of chronic inflammation of 
the urinary bladder, are probably equally useful in the treatment of 
pyelitis. If the stomach be irritable, as it not unfrequently is, our 
treatment must be modified with the object of overcoming this irrita- 
bility. When there is clear indication of the formation of an abscess 
in or around the kidney, an early and free opening should be made 
into it, for by that means not only may the extension of the abscess in 
other directions be prevented, but the cure of the disease will not im- 
probably be effected. 



NEPHRITIS. BRIGHT'S DISEASE. 

Causation. — The causes of inflammation of the substance of the 
kidney and of congestion (which is clinically undistinguishable from 
inflammation) are chiefly the following: obstruction of the renal artery 
or its branches by any impediment, but more particularly by thrombi, 
or cardiac or pysemic emboli; venous engorgement taking place in 
obstructive heart disease, and in chronic affections of the lungs; the 
presence of certain inflammatory affections, such as erysipelas, or of 
certain specific fevers, more especially scarlet fever and diphtheria; 
exposure to cold and wet ; the influence of various irritants, among 
which may be included cantharides, turpentine, perhaps lead and 
alcohol ; and possibly the presence of urate of soda in the blood, or at 
any rate the presence of the conditions which determine or flow from 
gout ; and the extension of inflammation by continuity from neighbor- 
ing parts, more particularly the mucous membrane of the pelvis and its 
diverticula. 

1. Circumscribed and Suppurative Inflammation. 

Morbid Anatomy. — The results of arterial thrombi or emboli are the 
- same in the kidney as elsewhere. If the obstructed vessel be of large 
or medium size, the district or area to which it leads becomes deeply 



SUPPURATIVE NEPHRITIS. 



773 



congested, the blood accumulates and stagnates in the arteries, veins, 
and capillaries of this area, and escapes from them, by rupture or \ 
otherwise, not only into the intertubular tissue but into the Malpighian 
capsules and convoluted tubules. The affected district is at first of a 
deep red or reddish-black color and well defined, resembling a patch 
of pulmonary apoplexy ; but gradually it becomes decolorized and 
acquires a more or less opaque, buff-colored, cheesy aspect. Sometimes 
it softens, sometimes suppurates. In the embolism due to cardiac dis- 
ease, and especially in that occurring in pyaemia, the infarctions are for 
the most part very small and numerous, and speedily suppurate. In 
such cases, on removing the capsule, small beads of pus surrounded by 
a congested halo may be seen projecting from the surface of the organ ; 
and on making a vertical section small abscesses or groups of abscesses, 
similarly surrounded, may be seen extending in a radial direction from 
the periphery to the mucous surface. These may vary from mere points 
up to the size of a filbert or a walnut. They originate in the intertu- 
bular spaces, but soon involve and destroy the tubules themselves and 
the other renal structures. When inflammation extends from the pelvis 
of the kidney there are often general congestion and enlargement of 
the organ ; but the special feature of such extension is the formation, 
in the medulla and in the cortex, of minute close-set abscesses grouped 
in comparatively large and well-defined but not very numerous clus- 
ters. Abscesses developed in the substance of the kidney are attended 
with various results. Sometimes their contents gradually concrete into 
a substance like thick cream or moist plaster of Paris, consisting of 
disintegrated and fatty cells, molecular matter (partly earthy, partly 
oily), and cholesterin. In the most remarkable examples of this kind 
of change the glandular substance of the kidney is hollowed out into a 
series of cavities, each one corresponding to a medullary cone and its 
associated cortical lobule, which are bounded externally, and separated 
from one another and from the pelvis by thin fibrous laminae or dis- 
sepiments. Sometimes they open and discharge their contents into the 
infundibula ; sometimes they extend beyond the limits of the kidney ; 
and in either case become then indistinguishable, pathologically and 
clinically, from suppuration following upon pyelitis. 

Symptoms. — It would be almost impossible to lay down any definite 
rules for our guidance in reference to the diagnosis of the above affec- 
tions. In a large number of cases the renal symptoms are necessarily 
more or less completely masked by the graver morbid conditions with 
which they are associated. Thus when renal abscesses result from 
embolism, pyaemia, or inflammation commencing in the pelvis of the 
kidney, the febrile or typhoid symptoms referable to the primary 
malady may perhaps be in some degree aggravated, the prospects of 
amelioration may be somewhat diminished, or the fatal event may be 
hurried ; but probably nothing points specially to implication of the 
substance of the kidney. Even if the urine be scanty or contain blood, 
albumen, casts, pus-cells, or leucocytes, there is nothing to show that 
such conditions may not be the result of some other variety of renal 
inflammation. If large abscesses form, the symptoms and consequences # 
will be those of suppurative pyelitis. 



774 DISEASES OF THE GENITO - URINARY ORGANS. 



The treatment of these cases (if they call for treatment) will be the 
same as that of pyelitis. 

2. General Acute Inflammation. Acute Bright 1 s Disease. 

Morbid Anatomy. — In inflammation the result of exposure or of the 
operation of febrile disorders, the morbid process involves in a greater 
or less degree, and with more or less uniformity, the whole texture of 
the kidney, the epithelial lining of the renal tubules, as well as the 
vessels and the connective tissue in which the vessels are imbedded. 
Indeed, the involvement of the epithelium is so marked a feature that 
the affection has been termed " tubal " or " desquamative nephritis." 
The epithelium and more especial^ that situated in the cortical ducts 
becomes swollen and cloudy, so that these become distended and opaque, 
and their channels narrowed or obliterated. The renal vessels get dis- 
tended with blood, but more especially those which are not compressed 
by the swollen tubules, namely, those of the Malpighian bodies, the 
stellate vessels on the surface, and those of the medulla. Further, 
more or less inflammatory exudation takes place into the interstitial 
tissue, and also into the Malpighian capsules and the tubules. The 
latter result is indicated by the presence of hyaline or granular matter, 
or of blood between the Malpighian tufts and capsules, and in the axes 
of the tubules. An inflamed kidney presents various characters accord- 
ing as the distension of the vessels with blood or that of the tubules 
with epithelium predominates. In both cases the organ becomes large 
and soft, and the capsule readily peels off; but in the former case the 
wmole of the secreting structure, cortex as well as medulla, becomes of 
a deep red or claret color; in the latter case the medulla is congested 
generally, but the cortex, though studded with congested patches, is 
usually remarkable for its opacity and pallor, resembling in this respect 
a hepatized lung. When this variety of nephritis is present there is a 
tendency for the affected epithelium to be thrown off, and for the 
development of new epithelium in its place, wmich latter soon assumes 
the form of embryonic cells, or cells differing little if at all from those 
of pus. And hence the casts which are found in the urine comprise, in 
different proportions, not merely hyaline, or granular, or bloody casts, 
but also cylinders consisting mainly of modified renal epithelium, and 
cylinders composed partly of amorphous exudation and partly of the 
various cells which form in the renal tubules. The results of acute 
nephritis are various. Sometimes at the end of a few days, of a few 
weeks, or even of a few months, the morbid processes come to an end, 
and the kidneys revert to their healthy condition or to a condition 
which is practically healthy, but in which a few Malpighian bodies 
and tubes remain permanently atrophic. In other cases the disease 
becomes chronic, and various structural changes which will be discussed 
further on slowly ensue. 

Symptoms and Progress. — The symptoms of acute nephritis vary very 
much in their severity, and are sometimes so trivial as to pass unob- 
served. They consist mainly in slight fever, aching across the loins, 
an abnormal state of the urine, and anasarca. The febrile phenomena 



NEPHRITIS 



— ACUTE BRIGHT ? S DISEASE. 



775 



comprise quickness and hardness of pulse, slight elevation of tempera- 
ture, heat and dryness of skin, clamminess of mouth with coating of 
tongue, thirst, loss of appetite, perhaps nausea and sickness, and head- 
ache. From the commencement, probably, the patient notices that his 
water is remarkably scanty. A few ounces only may be passed in the 
course of the day and night, or there may be complete suppression for 
many hours. What is passed is abnormally dark and often turbid or 
grumous. Its specific gravity is high ; it contains abundant albumen, 
often blood, and a diminished quantity of urea ; and, microscopically, 
it presents epithelial, hyaline, granular, or bloody casts. It often also 
contains amorphous urates and uric acid crystals. Anasarca usually 
comes on early. It usually manifests itself first in the face, more es- 
pecially in the eyelids and conjunctivae, or in the genital organs. But 
it soon becomes general, and may become enormous, especially in the 
organs last named and in the most dependent parts. The surface at 
the same time assumes for the most part a peculiar pale waxy aspect. 
Dropsy is not, however, limited to the surface; but may take place 
into the various serous cavities and into the tissues of different inter- 
nal organs, causing difficulty of breathing and various other special 
symptoms. 

The symptoms, however, are by no means always in accordance with 
the above sketch. Sometimes the anasarca is the first intimation that 
the patient or his doctor has that the kidneys are affected, and it is 
only on further inquiry that the urine is found to be abnormal. Some- 
times growing anaemia and weakness alone point to the kidney affec- 
tion, which the examination of the urine then detects. Sometimes 
almost the first indication of disease is the presence of palpitation, or- 
thopnoea, and lividity of surface, without any discoverable lesion of 
either the heart or lungs. And in some cases the urine is scanty, albu- 
minous, and bloody, and yet no anasarca, and scarcely any other indi- 
cations of impaired health manifest themselves. 

The progress and results of acute nephritis are very various. In a 
large proportion of cases recovery takes place, sometimes at the end of 
a week or two, more frequently at the end of six weeks or two months, 
occasionally after the lapse of six or twelve months or more. The 
symptoms of returning health are chiefly the restoration of the func- 
tions of the skin, the subsidence of the anasarca, and the return of the 
urine to its normal quantity and character. The anasarca usually 
subsides before the urine becomes free from albumen. It is not un- 
common, however, especially after scarlet fever, for the anasarca to 
continue some little time after the urine has acquired its healthy char- 
acter. In a smaller proportion of cases, but unfortunately in far too 
many, the affection either ends fatally while it is still acute, or assumes 
a chronic and incurable character. The fatal event may occur at dif- 
ferent periods, and may depend on one or other of the following causes : 
1. (Edema of vital organs, as of the larynx, or of the tissue of the lungs, 
producing dyspnoea, lividity, palpitation, asphyxia; 2. Inflammation 
of the pericardium, pleurse, lungs, or peritoneum; 3. Anaemia and 
asthenia; and 4. Cerebral symptoms, especially coma and convulsions. 

Treatment. — In the treatment of acute nephritis it is important, if 



776 



DISEASES OF THE G ENITO - URINARY ORGANS. 



possible, to assuage the inflammation which is in progress. For this 
purpose, counter-irritation to the loins by means of mustard plasters 
or dry cupping may be employed, or the abstraction of blood by leeches 
or cupping. It should be noted that cantharicles ought never to be 
employed for the former purpose, and that the removal of blood is gen- 
erally not advisable. The patient should be kept warm in bed and 
clothed in flannel ; warm or hot baths should be occasionally adminis- 
tered for the purpose of promoting the action of the skin ; and the 
bowels should be kept moderately free. To restore the function of the 
kidneys the measures just enumerated undoubtedly conduce. But, as 
is strongly urged by Dr. Dickinson, it is important also to remove from 
the kidneys the solid cylinders which are blocking up the tubules, and 
by their pressure obstructing the efferent veins ; to this end the secre- 
tion of urine should, if possible, be promoted. It is uncertain how far 
diuretics are capable of effecting this purpose ; but it seems, at all 
events, judicious to encourage the patient to drink water and to take 
fluid nourishment, and to administer diuretic doses of the acetate or 
citrate of potash and other equivalent medicines. Digitalis is specially 
recommended by Dr. Dickinson. At a somewhat later period, when, 
in addition to other symptoms, anaemia is present, vegetable tonics and 
the preparations of iron are often of great value. The perchloride of 
iron, which is a diuretic as well as a tonic, is a favorite remedy. The 
patient's diet should be nutritious, but for the most part light, easily 
digestible, and farinaceous. Alcohol in any form is rarely needed, and 
generally likely to be injurious. There is a great tendency for ne- 
phritis to recur, and great care should therefore be taken of the patient 
during convalescence. 

3. General Chronic Inflammation. Chronic Bright' 's Disease. 

Morbid Anatomy. — In a considerable number of cases nephritis 
assumes a chronic form. The characters which the kidneys then ac- 
quire are very various, in dependence partly on the stage at which the 
disease has arrived, partly on the structures mainly involved, and the 
particular nature of the change going on in them. Among the 
various forms of kidneys thus chronically affected, four at least stand 
out prominently as types ; these are the smooth white kidney, the 
fatty or branny kidney, the contracted granular kidney, and the cystic 
kidney. 

1. The smooth white kidney is characterized mainly by the fact that 
in its case overdevelopment of the epithelial lining of the convoluted 
tubules is almost the exclusive element of the inflammatory process 
which has become perpetuated. The organ is two or three times as 
large as natural, perfectly smooth on the surface, and throughout its 
whole cortex (which is disproportionately swollen) pale, opaque, and 
almost homogeneous in texture. There is little or no change in the 
Malpighian bodies, and the epithelium of the cortical tubules is abun- 
dant, swollen, and more or less granular. The tubules contain mucous, 
granular, and hyaline casts. 

2. The Fatty Kidney. — In another form more or less fatty transfor- 



NEPHRITIS 



— CHRONIC BRIGHT'S DISEASE. 



777 



mation of the exuded matter or of the affected tissues takes place. The 
fibrinous exudation within the Malpighian capsules and into the 
tubules not unfrequently becomes studded more or less thickly with 
fatty globules of small size. The epithelial cells also frequently be- 
come the seat of fatty change. In some cases this occurs in cells which 
in other respects seem fairly healthy. In other cases the cellular con- 
tents of whole tubules become broken down into an almost uniform 
mass of fatty detritus. And in other cases, again, single cells, epithe- 
lial or embryonic, assume the characters of granule cells. But fatty 
degeneration takes place also in the renal vessels and in the connective 
tissue of the organ. The Malpighian vessels are sometimes thickly 
studded with oily globules ; and the same may be observed in the in- 
terior or in the parietes of the intertubular vessels, and densely accu- 
mulated in all parts of the intertubular spaces. The fatty change is 
generally not universal or uniform, but occurs, for the most part, with 
especial intensity in patches, the presence of which, owing to their pe- 
culiar opaque buff color, gives to the cortex the appearance of being 
dusted with bran. It may be added here that even the abundant de- 
position of oil in the renal epithelium is not in all cases evidence of 
fatty degeneration. Fatty deposit occurs here, as well as in the hepatic 
cells, under various conditions which are independent of disease in 
the organ, and is compatible with the healthy performance of its 
functions. 

3. The Contracted Granular Kidney. — In this case the organ shrinks 
in size, its surface becomes granular, its capsule thickened and ad- 
herent, its texture indurated; and microscopically the Malpighian 
bodies and convoluted tubules are found atrophied and variously modi- 
fied. There can be little doubt that the acutely inflamed organ may 
pass into the smooth white kidney, that this may after a time undergo 
fatty change, and that ultimately the degenerated tissues may waste, 
the fat become more or less completely removed by absorption, and the 
contracted granular kidney ensue. It is certain, however, that the 
history of the great bulk of cases of contracted granular kidney is not 
in accordance with the sequence of events ; that, on the other hand, 
the morbid processes resulting in this change are, like those which pro- 
duce cirrhosis of the liver, insidious in their onset and in their prog- 
ress, and reveal themselves only by symptoms when the disease is far 
advanced. Apart from the distinctly inflammatory origin, in certain 
cases, of the contracted granular kidney, the setiology of the affection is 
obscure. In many cases it creeps on with advancing years without 
any apparent cause ; in other cases, however, we meet with it in per- 
sons who have led intemperate lives, who have been habitual drinkers, 
who have suffered from syphilis, who have been victims to gout or are 
of gouty parentage, and in painters and others who have had lead- 
colic or palsy. The granular kidney in its typical form is much smaller 
than the healthy organ, and occasionally not more than half an ounce 
or an ounce in weight; its capsule is adherent, and on removing it the 
surface is found nodulated like that of a cirrhosed liver (the nodules 
being perhaps as large as hemp-seeds) or else very finely granular, and 
of a deep reddish hue. On section the cortex is found to be much 



778 



DISEASES 0E THE GENITO -URINARY ORGANS. 



reduced in thickness, and the cones atrophied, though in a less degree ; 
and probably a number of cysts of various sizes will be found studding 
the secreting structure. On microscopic examination, the Malpighian 
bodies are seen to be largely changed ; they are much diminished in 
size, their capsules are thickened, and their capillary tufts welded into 
almost homogeneous lumps ; the convoluted tubules are more or less 
atrophied, sometimes denuded of epithelium, sometimes filled with 
hyaline or granular casts, sometimes reduced to fibrous filaments or 
bands, scarcely distinguishable from the surrounding tissues, sometimes 
converted into strings of microscopic cysts lined or not with distinct 
epithelium ; the vessels, more especially the arteries, are greatly 
thickened and at the same time reduced in calibre, the larger ones are 
probably also atheromatous ; and finally the connective tissue of the 
organ has become hypertrophied to a greater or less extent, especially, 
as Dr. Dickinson points out, on the outer aspect, whence it is pro- 
longed into the substance of the organ. The changes, allowing for the 
different glandular elements which are implicated, are, in fact, almost 
exactly the same as are observed in the liver in cirrhosis of that organ. 
The same changes occasionally affect portions only of otherwise healthy 
kidneys ; and they also manifest themselves ultimately in the attenua- 
ted and compressed kidney-structure which results from hydrone- 
phrosis. Further, in a very large number of cases the fatty and the 
contracted condition of kidney exist in association. 

4. The Cystic Kidney. — It is difficult to make any practical distinc- 
tion between the cystic kidney and that which has just been described, 
notwithstanding that in the former the organ may attain the bulk of 
a bullock's kidney, and the latter is usually remarkably reduced in 
weight. It has been mentioned that in the granular kidney obvious 
cysts are of common occurrence. There is no limit to their size and 
number ; the cause which produces them at one or two points in one 
case may be in general operation in another, and hence, instead of half 
a dozen, we may have hundreds or thousands, and instead of being no 
larger than a pea or marble, many of them may attain the size of a 
pigeon's egg or a still greater bulk. In some of the more remarkable 
cases of this kind the kidney may constitute an easily recognizable 
tumor, and post mortem may have the aspect of a multilocular ovarian 
growth, consisting of little else than a congeries of cysts, probably 
measuring seven or eight inches in length, and weighing between two 
and three pounds. The contents of such cysts vary in character even 
in the same case. They are sometimes limpid, sometimes thick and 
treacly, sometimes solid and jelly-like. They may be colorless or 
straw colored, or may present any tint between this and a dark brown 
or red. They may be clear, turbid, or opaque. They usually contain 
more or less albumen and the ordinary salts of the serum, but rarely, 
if ever, any special urinary constituents. The more viscid accumula- 
tions probably contain colloid matter. Among microscopic constitu- 
ents are observed in different cases granular or fatty matter, disinte- 
grating cells, decomposing blood, and cholesterin. Further, the cysts 
are often lined with pavement-epithelium. The origin of these cysts 
is obscure. There is reason, however, to believe that they originate 



NEPHRITIS — CHRONIC BRIGHT'S DISEASE. 



779 



both in Malpighian bodies and in portions of renal tubules which, 
owing to inflammatory or degenerative changes, have been cut off from 
their connection with the rest of the secreting structure of the kidney. 
The abundant microscopic cysts which may be observed in many cases 
of granular kidney almost certainly originate in the convoluted tubules 
which, losing their epithelium, and undergoing degeneration, become 
obliterated at points, while the intervening portions become distended, 
and give to the tubes a moniliform character. Another view, originally 
proposed by Mr. Simon, is that they arise in extravasated and over- 
growing or dropsical renal epithelial cells. 

It is a curious fact that, in some of the most typical cases of cystic 
kidney, similar cysts have been present in abundance in the liver. 

Symptoms and Progress. — The symptoms which mark the presence 
of the large pale kidney and of the fatty kidney differ little from those 
which are present during the later periods of acute nephritis ; indeed, 
as has been already stated, the several conditions of kidney here referred 
to represent for the most part merely different stages of the same dis- 
ease. There is generally the history of previous acute attacks, and it 
must be added that not unfrequently acute symptoms supervene from 
time to time in the course of the chronic disease. The special indica- 
tions of the affections here considered are: great anaemia and anasarca; 
scanty, but for the most part pale urine, with casts, which are either 
hyaline or granular, or studded with cells, and which often present dif- 
fused or aggregated fatty globules and granule cells ; and a great ten- 
dency to the various complications (inflammatory and other) which 
have been already considered. When exacerbations take place blood 
may be found in the urine, as in the acute affection. 

The symptoms referable to the granular kidney, or to its cystic modi- 
fication, come on, unless they have been preceded by those of the acute 
affection, insidiously and late in the progress of the disease. Indeed, 
it often happens that it is the supervention of some complication that 
first calls attention to the condition of the kidney. The patient, who 
had formerly perhaps enjoyed good health, becomes thin, weak, and 
anaemic, without obvious cause; he has some loss of appetite and 
nausea, and perhaps actual sickness; he complains of shortness of 
breath and palpitation ; he is liable to bronchitic attacks ; his eyesight 
becomes more or less impaired ; and he perhaps notices that he passes 
more water than he had been accustomed to pass, and that he has to 
get up several times in the night to pass it. Gradually failing health, 
and the presence and persistence of some or all of the symptoms which 
have been enumerated, at length lead to a medical investigation, and 
the urine is found to be of persistently low specific gravity, and to con- 
tain probably more or less albumen. In other cases attention is first 
seriously directed to the patient's condition in consequence of the occur- 
rence of pufnness of the eyelids or swelling of the legs or scrotum. In 
others again the first decided intimation of disease is the supervention 
of severe sickness and diarrhoea, or of paroxysms of extreme difficulty 
of breathing, or of oedema of the larynx, or of uraemic convulsions, or 
of an attack of apoplexy. [The presence of persistent headache, which 
cannot be otherwise explained, especially if the pain is seated at or near 



780 



DISEASES OF THE GENITO - URINARY ORGANS. 



the crown of the head, should always arouse suspicion as to the pos- 
sible existence of granular degeneration of the kidneys.] The symp- 
toms, indeed, are multiform, and they are frequently masked by the 
presence of associated visceral lesions, more especially of the heart, 
lungs, liver, intestinal canal, and brain, of which some must be regarded 
as consequences of the renal disease. Nevertheless, certain morbid 
phenomena are due to the renal disease, and indicate its presence, and 
to them we will now direct attention. The urine is almost always 
abundant, pale, limpid, and acid. Three or four pints, or even more, 
may be habitually passed during the twenty-four hours. Its specific 
gravity is low, varying from about 1003 or 1004 to 1010 or 1012, and 
it contains but little urea (on the average, Dr. Roberts says, 100 grains 
daily) or other normal urinary constituents. Albumen is generally 
present, but in small proportion, and is occasionally altogether absent. 
Microscopic casts, too, are in small numbers, and may be readily over- 
looked; they are, for the most part, hyaline or slightly granular. The 
condition of the urine may, however, vary ; occasionally it is scanty, 
high colored, and of high specific gravity, and occasionally it contains 
blood, and casts different from those which have been mentioned. 
These variations may be due to the occurrence of exacerbations, or to 
the fact that the condition of the kidney is not one of simple atrophy. 
Dropsy, so common in other forms of Bright's disease, is very often 
absent here, and, even when present, is generally slight and variable; 
sometimes, however, it becomes extreme. It is in association with the 
contracted granular kidney that typical vascular lesions mainly occur, 
namely, thickening of the walls of the small arteries, and hypertrophy 
of the muscular walls of the heart. The amount of these changes is 
generally proportioned to the length of time during which the renal 
disease has been in progress, and to the degree in which the kidneys 
have become contracted. The hypertrophic condition of the heart may 
generally be ascertained by its heaving pulsation, and by the increased 
area of its dulness, and the general vascular affection by the tension of 
the larger arteries, and by the incompressibility and prolonged tidal 
wave of the pulse. 

The causes of death in granular degeneration are very various. In 
the first place the patient is liable to all those incidents which bring 
about a fatal result in the acuter forms of Bright's disease, namely, 
inflammation of serous membranes and of the lungs; oedema of the 
larynx, anaemia; vomiting, and diarrhoea, with the debility and ex- 
haustion which they induce ; and ursemic convulsions and coma. In 
the second place, there is a notable tendency in cases of this sort for 
the arteries to become atheromatous and calcareous, and consequently 
readily lacerable ; and the heart being at the same time enlarged, the 
small vessels contracted, and the blood pressure in the arteries increased, 
death by hsemorrhagic effusion into the substance of the brain is not 
uncommon. And in the last place, granular degenerative changes in 
the kidney are frequently associated with similar changes in the liver 
and other organs, and death results from the collective influence of 
several causes. It may be added, as circumstances tending to cause 
death, that epistaxis, hsemateinesis, and pulmonary apoplexy are of not 



NEPHRITIS — CHRONIC BRIGHT's DISEASE. 



781 



unfrequent occurrence, and that thrombi are apt to form before death 
both in the systemic vessels and in the cavities of the heart ; and fur- 
ther that it is in this, rather than in the acuter forms, that retinal 
haemorrhage is observed. 

Although granular disease of the kidneys may be met with at every 
age from puberty onwards, it is mainly a disease of advancing years, 
and in this respect differs markedly from the other forms of kidney dis- 
ease which have been discussed. The prognosis is of course in the 
highest degree unfavorable, but the time which may elapse before 
death ensues is often very considerable. It is certain that the disease 
may be prolonged for ten years or more. 

Treatment. — In the treatment of the large pale, and of the fatty 
kidney, counter-irritation and local abstraction of blood are generally 
quite uncalled for. Diuretics may be somewhat more freely adminis- 
tered than in the acute affection, and, among others, juniper, broom, 
and nitric ether. Purgatives and diaphoretics are also of especial 
value, not so much perhaps to benefit the kidneys as to promote the 
discharge of water from the system and the elimination of effete mat- 
ters. Watery purgatives, Epsom salts, bitartrate of potash, jalap, 
scammony, elaterium, and the like, may be administered in efficient 
doses two or three times a week ; and hot water or vapor baths or 
even the Turkish bath may be used with equal frequency. But be- 
sides these measures, and perhaps above them, ferruginous and other 
tonics are of great value. It need scarcely be added that the patient 
should, as in the acute disease, be carefully protected against the influ- 
ence of cold ; at the same time change of air and gentle exercise in 
warm weather are often beneficial. The diet, though nutritious, should 
be for the most part farinaceous, and not more abundant than is requi- 
site to supply the actual needs of the patient. 

In treating cases of granular disease the incurability of the lesion 
must not be forgotten. If no special symptoms are present it may be 
desirable to promote the action of the skin by the wearing of flannel 
and by the use of baths, to keep the bowels freely open by occasional 
mild purgatives, to give tone to the system by the employment of iron 
in combination with vegetable bitters, and to support strength by a 
fairly nourishing diet, not superabundant in quantity, and comprising 
a small proportion only of animal food. Circumstances may render 
the exhibition of alcohol necessary, but in most cases there is little or 
no need for its administration. 

Special symptoms must in all forms of Bright's disease be treated as 
they arise. For dropsy, the most efficacious remedial measures have 
already been enumerated. It may be added that acupuncture is often 
necessary. It should not be forgotten, however, that erythema, and some- 
times sloughing, follow this slight operation, apparently from the irrita- 
ting effects of the escaping serum on the integuments over which it flows. 
To obviate this danger it is well to anoint the surface previously with 
sweet oil. Ursemic poisoning may often be averted, or temporarily 
cured, by the use of drastic purgatives. When convulsions are present, 
the inhalation of chloroform often affords relief. It is needless to lay 



782 



DISEASES OF THE GENITO- URINARY ORGANS. 



down any special rules w T ith regard to the treatment of other complica- 
tion and sequelae. 

4. Congestion. 

Morbid Anatomy. — This condition, which arises chiefly in the course 
of obstructive cardiac and pulmonary diseases, is characterized in its 
early stage by congestion, enlargement, and softening of the kidneys. 
The veins are especially overloaded, and more particularly the stellate 
veins of the outer surface. If the congestion continue, induration takes 
place, due to slow increase of the interstitial fibrous tissue of the organ, 
and ultimately more or less atrophy of the Malpighian bodies and of 
the other secreting elements. 

Symptoms. — In this affection there is not generally much to attract 
attention to the condition of the kidneys beyond scantiness of urine, 
and the presence in this secretion of more or less albumen, and occasion- 
ally blood, and of casts which are hyaline or granular, or formed in 
part or wholly of disintegrating blood-corpuscles. The specific gravity 
is usually high. Inflammation readily supervenes. As a rule the gen- 
eral symptoms due to renal congestion are so inextricably intermingled 
with those of the disease to which the congestion itself is due, and 
which in fact they closely resemble, that they do not admit of sepa- 
rate recognition. Occasionally, however, uraemic poisoning and other 
common consequences of Bright's disease are distinctly developed. 

The treatment is mainly that of cardiac or pulmonary disease, as the 
case may be; and the employment of remedies calculated to relieve 
renal congestion, more especially purgatives, diaphoretics, and unirri- 
tating diuretics. 



TUBERCULAR DISEASE OF THE KIDNEY. 

Morbid Anatomy. — Tubercles are developed in the kidney mostly as 
a comparatively late event of general tuberculosis, give rise to few or 
no symptoms, and are of little clinical importance. Sometimes, how- 
ever, tuberculosis is primary in the kidneys, or at all events may be 
found post mortem to be as far advanced in these as in other organs ; 
and under such circumstances the renal affection is a material, possibly 
the chief, item of the patient's illness. When tubercles are abundant 
and far advanced in the kidneys, they are frequently at the same time 
present in the mucous membrane of the urinary organs, the pelves, the 
ureters, the bladder, and even in the vesicular seminales and testes of the 
male, or in the uterus and Fallopian tubes of the female. 

Tubercles appear in the first instance as gray granulations scattered 
mainly in the cortex, but also occurring in the medulla. It is in this 
form that they are generally discovered. After awhile they increase 
in number and in size, coalesce into larger masses, undergo caseous de- 
generation, soften, and perhaps suppurate. 

Under such circumstances the kidney may become considerably en- 
larged, riddled with cavities of various sizes containing either cheesy 



TUBERCULAR DISEASE OF THE KIDNEY. 



783 



matter or tubercular detritus or pus, and studded in the intervals with 
unsoftened tubercles. The destructive process may proceed so far, in- 
deed, that the whole of the secreting structure becomes converted into 
a series of large tubercular cavities, of which one corresponds to each 
cone and its associated portion of cortex. These cavities may either 
communicate by ulceration with the cavity of the kidney, or may re- 
main separated from it, in which case the contents dry up after a time 
into a creamy or mortary material resembling that which has already 
been adverted to as resulting from the drying up of ordinary renal ab- 
scesses. 

Tubercles affect the mucous lining of the pelvis and ureter in pre- 
cisely the same way as they affect other mucous surfaces; miliary granu- 
lations appear scattered in groups in the substance of the membrane, 
become caseous, and then disintegrate, producing by their disintegra- 
tion shallow circular pits, the surfaces of which generally present more 
or less tubercular detritus. The junction of neighboring ulcers leads to 
the destruction of a greater or less extent of surface, and the formation 
of an irregular sinuous-edged ulcer. There is generally also more or 
less thickening of the subjacent and surrounding tissues. 

Symptoms and Progress. — In considering the symptoms of renal 
tuberculosis it is almost impossible to separate them practically from 
those due to the associated affection of the urinary passages ; and it is 
not difficult to surmise what the main symptoms of these united con- 
ditions must be. The symptoms, indeed, are essentially those of chronic 
pyelitis. They mostly comprise pain and tenderness in the loins, irri- 
tability of bladder, with perhaps pain or scalding in passing water, and 
the secretion of urine containing a greater or less abundance of mucus, 
but more generally of pus, and occasionally perhaps a little blood. 
The urine is said generally to be scanty, and not to contain renal casts ; 
but the presence of renal casts must not be taken to disprove the pres- 
ence of renal tubercle, nor is the scanty secretion of urine by any 
means constant. The reaction of the urine is for the most part slightly 
acid; but, as in cases of non-specific pyelitis and cystitis, is apt to be- 
come alkaline from decomposition. The course of renal tuberculosis 
is essentially unfavorable, for, independently of the slow but sure de- 
struction of the renal tissue, which must ultimately lead to a fatal issue, 
the local disease sooner or later becomes associated with the develop- 
ment of tubercles in other organs. The symptoms and progress of any 
case will necessarily vary according as the phenomena due to the uri- 
nary organs or those due to the implication of other organs preponderate. 
It is important to bear in mind that the symptoms of renal tubercle 
and of tubercle of the urinary passages are not in any sense specific; 
and that their diagnosis must mainly rest on the detection of similar 
disease in the lungs or elsewhere. 

Treatment — The treatment of renal tubercle comprises that of tuber- 
culosis and that of chronic pyelitis. 



784 DISEASES OF THE GENITO - URINARY ORGANS. 



SYPHILITIC DISEASE OF THE KIDNEY. 

Lardaceous infiltration of the kidney is a common attendant on 
advanced syphilitic cachexia; but specific syphilitic affections of this 
organ are exceedingly rare. Very few cases indeed of distinct gum- 
matous tumors are recorded ; but occasionally, on examining the bodies 
of persons who have suffered from syphilis, and in whom gummata or 
their remains are visible in other organs, the surface of the kidney 
presents well-marked linear and stellate depressions corresponding to 
localized induration and atrophy of tissue. These are most likely of 
syphilitic origin ; but have probably never given any indication during 
life of their presence. As regards diagnosis, all that can be said is 
that when patients with advanced syphilis present symptoms indica- 
tive of renal disease, they are probably due to lardaceous infiltration, 
but may possibly result from the formation of gummata. 



MOEBID GROWTHS OF THE KIDNEY. 

Morbid Anatomy. — Several varieties of tumor are met with in the 
kidney. Fibrous tumors sometimes attain a large size, so large, in 
fact, as to be easily recognizable during life. But they do not, so far 
as we know, produce any inconvenience or symptoms beyond such as 
depend on their situation and bulk. The only tumors, however, that 
have any practical interest are lymphadenomatous growths and cancer. 

1. Lymphadenoma generally occurs in the kidney as a secondary or 
late event in the gradual generalization of the disease. The renal 
growth occurs in patches which at the surface of the organ are circular, 
pale, and scarcely elevated, and which are prolonged into its substance 
in a wedge-like form. Other patches are wholly imbedded in the 
substance of the organ. On microscopic examination the cells which 
constitute the growth are found to occupy the intertubular spaces 
only — the tubules and Malpighian bodies, which probably remain 
healthy, being surrounded and separated from one another by them. 

2. Carcinoma may be primary or secondary. When secondary it j 
rarely attains large dimensions ; when primary it is generally limited 
to one kidney, and this soon forms an enormous tumor. Renal car- 
cinoma is, almost without exception, of the encephaloid variety. It 
commences in the form of one or more isolated tumors, which grad- 
ually invade the adjacent renal structure until the greater part or the 
whole of the organ becomes involved. While this process is going on 
the kidney becomes enlarged, but still probably on section presents 
the outlines of its original elements. With the continuance of the 
growth, however, all traces of the renal structure become obliterated, 
and the kidney is converted into a simple carcinomatous mass, still 
probably presenting the form of the healthy organ, but attaining the 
size it may be of a cocoanut or large melon, and weighing several or 



MORBID GROWTHS OF THE KIDNEY. 



785 



many pounds. In the process of its growth it becomes adherent to 
surrounding tissues and organs which may then be involved by con- 
tinuity; and it develops nodular, or papillary, or even villous out- 
growths into the cavity of the pelvis and infundibula. The carci- 
nomatous kidney is of course liable to all those changes which generally 
characterize carcinoma; it presents consequently, in addition to growing 
tissue, patches or networks of caseous and fatty degeneration, hemor- 
rhagic effusions, and tracts of liquefaction. The ureter is not unfre- 
quently involved, and, even when not distinctly cancerous, is apt to 
become thickened and more or less completely occluded. 

Symptoms and Progress. — The recognition of secondary growths in 
the kidney, whether they be lymphoid or carcinomatous, is a matter of 
little importance; and that of primary carcinoma is, until the disease 
is far advanced, often extremely difficult. The chief circumstances to 
be taken into consideration in arriving at a diagnosis are : first, the 
very gradual development of symptoms; second, the frequent discharge 
of blood in quantity with the urine; third, the gradual formation of a 
tumor in the situation of the kidney ; fourth, the appearance of second- 
ary cancerous growths ; and, fifth, the occurrence of progressive ema- 
ciation, debility, and cachexia. The symptoms, in fact, are mainly 
those common to cancerous growths, together with such as depend on 
the situation of the tumor and modification of the urinary secretion. 
Of these three symptomatic groups the latter two only call for further 
remark. The development of cancerous tumors is sometimes painless; 
sometimes, on the other hand, the patient suffers from frequent parox- 
ysms of the most intense agony ; and generally sooner or later there is 
manifest local tenderness. The tumor is characterized by originating 
.deep in the lumbar region, and (as it grow T s and fills more or less of 
the abdominal cavity) partly by its position, partly by its fixation, 
partly by its general rounded form, and very importantly by the fact 
that it is almost invariably crossed by the ascending or descending 
colon, the presence of which may often be seen, and always recognized 
by percussion. The veins in the abdominal Avails on the affected side 
are often much dilated ; and not unfrequently from the pressure of sec- 
ondarily affected glands, oedema of the corresponding lower extremity 
comes on. A cancerous kidney generally feels hard, but is sometimes 
yielding, and may be so soft as to give a deceptive sense of fluctuation ; 
it often enlarges so greatly as to fill its own side of the abdomen, and 
occasionally not only fills this, but encroaches to a great extent on the 
opposite side. It has been pointed out that the urine often contains 
large quantities of blood. Haemorrhages occur at irregular intervals, 
and are sometimes so profuse and frequent as to blanch the patient. 
It must not be forgotten, however, that in many cases no haemorrhage 
whatever takes place ; that in many the urine from first to last is per- 
fectly healthy. This latter circumstance is partly due to the fact that 
the ureter of the affected side often becomes impervious even at an early 
stage of the disease. Cancer-cells rarely if ever find their way from 
the kidney into the discharged urine, and, even if present there, would 
probably be undistinguishable from the epithelial cells of the bladder. 
The affection with which renal cancer is most apt to be confounded is 

50 



786 



DISEASES OF THE GENITO - URINARY ORGANS. 



renal calculus associated with pyelitis and distension of the cavity of 
the kidney. 

The liability to error is increased when gravel or small calculi are, 
as is not uncommon, present in the pelvis of the cancerous organ. In 
the early stages of cancer, indeed, it is often impossible to discriminate 
between it and calculous pyelitis. Later on its recognition is easy, but 
then the diseased organ is apt to be mistaken for an ovarian, splenic, 
or hydatid tumor. 

Treatment — In the treatment of renal cancer there is nothing to be 
done beyond endeavoring to relieve the patient's symptoms. Opiates 
are here invaluable. 



PARASITIC AFFECTIONS OF THE KIDNEY. 

Animal parasites seldom affect the urinary organs, at any rate in 
temperate climates. The Strongylus gigas and Pentastoma denticulatum 
have been so rarely observed in the kidney that no practical interest 
attaches to them. Hydatids are much more frequently met with there, 
and the Bilharzia hcematobia is common in the vessels of the urinary 
organs in certain tropical countries. 

1. Hydatid cysts of the kidney are far less common than hydatid 
cysts of the liver. Still many authentic cases are on record. The ana- 
tomical characters, progress, and consequences of renal hydatids present 
nothing distinctive beyond the facts that the enlarging cysts have the 
usual situation and connections of renal tumors, and that they not un- 
frequently rupture into the pelvis of the kidney and discharge their 
contents with the urine. It must not be forgotten, however, that hy- 
datid tumors may originate in the subperitoneal tissue in the neighbor- 
hood of the kidney ; and that both these and hydatids occupying other 
situations may open into the pelvis of the kidney or into the bladder. 
If suppuration takes place in the cyst of a renal hydatid, the case be- 
comes essentially one of abscess of the kidney. 

The treatment of renal hydatids is the same as that of hydatids of the 
liver. 

2. The Bilharzia hamiatobia seems to be the cause of an endemic 
form of hematuria, common in Egypt, at the Cape of Good Hope, and 
elsewhere. The parasite is of a worm-like form, and three or four 
lines in length. The female is longer than the male, and filiform ; the 
male is comparatively thick, and in the act of copulation incloses the 
female in a gynsecophoric canal. It is supposed to gain entrance into 
the system by the stomach, being swallowed with the food; but it speci- 
ally inhabits the mesenteric veins and those of the large intestine, blad- 
der, ureter, and pelvis of the kidney. Its presence in the small veins 
of the urinary organs gives rise to lenticular patches of inflammation 
in the mucous membrane, which yield mucus and sometimes blood, 
ulcerate, and discharge shreds of tissue "charged with ova. The patient 
consequently presents more or less irritability of the bladder, and passes 
urine containing these several ingredients. He often also falls into 



LARDACEOUS KIDNEY. 



787 



a state of antemia and debility. When the ureter or renal pelvis is 
affected, obstruction to the flow of urine may arise, pyelitis and hydro- 
nephrosis may ensue, and the patient's symptoms may assume a seri- 
ous character. The ova may form the nuclei of calculi. The pres- 
ence of these creatures in the mucous membrane of the large intestine 
is apt to produce dysenteric symptoms, which, however, are rarely se- 
vere. The recognition of the disease depends on the discovery of the 
ova in the urine. 

Treatment. — It is doubtful if vermifuge medicines are of any efficacy 
in this affection ; injections, however, into the urinary bladder may act 
beneficially on so much of the disease as involves that viscus. The 
forms of injection which are beneficial in the treatment of thread- 
worms naturally suggest themselves — namely, bitter infusions, or solu- 
tion of perchloride of iron. Dr. J. Harley prefers solution of iodide of 
potassium. For general treatment, tonic remedies are indicated. 



LARDACEOUS DEGENERATION OF THE KIDNEY. 

Causation. — The causes of lardaceous degeneration of the kidney are 
the same as those of lardaceous degeneration of the liver and other 
organs, and indeed the liver, kidneys, and spleen are generally concur- 
rently affected. 

Morbid Anatomy. — The lardaceous kidney increases in size with the 
amount of degeneration present, and may attain a weight of twelve 
ounces or more. When the disease is little advanced it is apt to escape 
recognition by the naked eye ; when, however, it reaches a high degree 
the organ is somewhat waxy, pale, and homogeneous in texture, and 
presents a slight degree of translucency. 

The morbid change usually commences in the vessels of the Mal- 
pighian tufts, but soon invades the Malpighian capsules, the walls of 
the convoluted tubules, and the intertubular vessels. The medulla, 
moreover, does not escape. The epithelial cells are rarely if ever in- 
volved, but are often granular, and even distinctly fatty. Lardaceous 
change is apt to be superadded in the course of ordinary fatty and 
granular degeneration of the kidney, in which case the several morbid 
conditions are variously intermingled. Hyaline casts may generally be 
detected in both the cortical and the medullary tubules. 

Symptoms and Progress. — The presence of lardaceous change in the 
kidney does not necessarily give rise to any special symptoms until the 
disease is very far advanced. The symptoms then, if not of themselves 
distinctive, become distinctive when the history of the patient, the con- 
dition of his other viscera, and his general symptoms are all taken into 
consideration. The symptoms due to the renal affection are as follow : 
the urine is increased in quantity, pale, of low specific gravity, and 
poor in urea, it contains more or less albumen, and casts which have 
not necessarily any special character, but are often hyaline and rarely 
if ever lardaceous; micturition is generally frequent; there is often 



788 



DISEASES OF THE GrENITO - URINARY ORGANS. 



some degree of anasarca, but it is not usually abundant; and the pa- 
tient is ansemic. In these respects the symptoms are not unlike those 
due to the granular kidney, but the heart does not become hyper- 
trophied ; there is absence of arterial tension ; there is little tendency 
to ursemic poisoning ; and although patients often suffer from serous 
inflammations, inflammation of the lungs, diarrhoea, vomiting, and 
haemorrhages, these complications are not distinctly referable to the 
kidney disease, but are due in part or wholly to the presence of asso- 
ciated visceral lesions. 

The treatment of lardaceous kidney is involved in the treatment of 
the affections to which it is secondary. Dropsy and other consequences, 
when they are sufficiently serious to demand separate attention, must 
be treated according to the principles already enunciated under the 
head of chronic Bright's disease. 



URINARY CONCRETIONS. 

Causation and Morbid Anatomy. — The presence in the urine, or the 
deposition from it, of uric acid and urates, of oxalate of lime, or of the 
phosphates, is occasionally observed in various morbid conditions of 
the system, and even in states of apparently good health. Such occur- 
rences rarely if ever call for medical interference. 

Occasionally, however, the appearance in the urine of one or other 
of these, or of other rarer crystalline matters, persists for some time, 
or becomes habitual. If under such circumstances symptoms of ill- 
health manifest themselves, medical treatment is obviously demanded ; 
and indeed, even in the absence of symptoms, the danger of the forma- 
tion of urinary calculi is so great that, if the pecularity of the urine 
be recognized, it should, if possible, be counteracted. 

The amorphous urates are sometimes found deposited in the renal 
tubules, but this is probably a post mortem phenomenon only. Urate 
of soda, in stellate masses of acicular crystals, is now and then dis- 
covered imbedded in the substance of the kidney; uric acid also, in 
solitary or clustered crystals, is occasionally detected within the tubules, 
and again, in the form of small calculi, is sometimes found loose in the 
cavity of the kidney or adherent to the mamillary processes. The 
same may be said in regard to the infinitely rarer xanthin and cystin 
concretions. 

Octahedra and dumb-bells of oxalate of lime, singly or in groups, 
may be met with in the urinary tubules, and occasionally also form 
small calculi, which lie loose or adherent within the cavity of the 
kidney. 

The phosphates are rarely deposited, except in ammoniacal urine, 
and as a consequence of the decomposition of that fluid ; they are, 
therefore, seldom, if ever, detected in the kidney except as secondary 
deposits around nuclei of other matters. Carbonate of lime, however, 
though much less frequently forming a urinary deposit, is occasionally 



URINARY CONCRETIONS. 



789 



met with in the form of small laminated globular concretions, either 
imbedded in the substance of the kidney, or free in its pelvis. 

The minuter concretions above described are sometimes discharged 
with the urine in considerable abundance, constituting what is called 
gravel. Small calculi, from the size of a pin's head to that of a horse- 
bean, are also not unfrequently transmitted, with more or less delay, 
along the ureter to the bladder, and thence into the chamber-pot. 
Sometimes a solitary calculus is thus discharged, and there is never 
more any recurrence ; sometimes large numbers of calculi are discharged 
at intervals. In other cases these bodies remain within the renal 
cavity, gradually grow there, and finally, perhaps, form a complete 
cast of the pelvis, infundibula, and calyces ; or there may be a consider- 
able number of smaller calculi aggregated into that form. 

The presence of calculi in the kidney generally leads to more or less 
pyelitis, and sometimes to suppuration, abscess, hydronephrosis, or 
some other serious consequence. 

Symptoms and Progress. — The symptoms which indicate the presence 
of " gravel " are : pain of an aching or burning character in one or 
other or both lumbar regions, shooting down to the testis or labium, 
and along the inner aspect of the thigh, together with frequent desire 
to micturate; some soreness or cutting pain during micturition, especially 
at the end of the penis in passing the last few drops; and nausea and 
sickness. At the same time the urine is generally clear, though it may 
deposit a greater or less abundance of a sand-like sediment, or show 
microscopic aggregations of crystals. 

A renal calculus may never reveal its presence by symptoms, and 
may even lead to the disorganization of the kidney without the least 
suspicion of disease having ever been excited. The special indications 
of the presence of a calculus are : first, the occasional occurrence of some 
aching or burning pain in the situation of the kidney, resembling but 
probably more severe than that attending the passage of gravel ; second, 
the occasional discharge of bloody urine ; and, third, the facts that the 
nephralgia and hematuria are often induced by jolting, jumping, and 
other forms of exercise, and that the pain may occasionally be relieved 
by change of posture. The pain becomes much more intense when the 
calculus enters the ureter, and continues intense so long as it is passing 
along it. The pain of renal or ureteric calculus may be traced along 
the ureter, shooting thence into the loin, radiating throughout the ab- 
domen and especially extending to the thigh and to the testis, which 
often becomes retracted ; it is attended with nausea and vomiting, and 
not unfrequently with rigors and faintness. Tenderness exists in the 
loin and along the course of the ureter, and pain is often increased by 
the voluntary attempts of the patient to flex the thigh on the abdomen. 
The pain due to the transmission of a calculus begins suddenly, and 
ends suddenly after a few hours, or with intermissions after a few days, 
in consequence of the stone becoming either arrested in its course or 
discharged into the bladder. It need scarcely be said that the micro- 
scopic investigation of the urine often throws important light on the 
diagnosis of cases which come under treatment ; and further that, when 
one kidney has already been destroyed by calculous or other disease, 



790 



DISEASES OF THE GENITO - URINARY ORGANS. 



the impaction of a calculus in the opposite ureter occasionally causes 
fatal suppression of urine. 

Treatment — The treatment of gravel and of renal calculus is for the 
most part identical with the treatment of pyelitis — a subject which 
has already been fully considered. The pain, however, in so-called 
"nephritic colic" is generally so much greater than in other forms of 
pyelitis that opium, rest, and local measures are all more urgently 
needed. Opium, especially, is our sheet-anchor. As valuable adju- 
vants we may enumerate purgatives, copious enemata, ice-bags, hot 
applications, or cupping to the loins, and especially the hot bath. 
Belladonna is sometimes useful when opium fails ; and, when a calculus 
is descending, may be of special service in relaxing the spasmodic 
action of the ureter which takes place around the calculus, and impedes 
its progress. The removal of a renal calculus by operative measures 
can scarcely be attempted unless the kidney be at the same time in a 
state of suppuration and have formed a manifest tumor. 

In the intervals between the acute attacks, which call, from their 
severity, for special treatment, the question of the removal of the con- 
ditions on which the gravel or calculi depend presents itself for consid- 
eration. Our action here must be determined mainly by the nature of 
the sabulous matter which is habitually discharged. 

If uric acid crystals or gravel are passed, it is certain that the urine 
is abnormally acid, and the exhibition of alkalies is demanded. The 
carbonate, acetate, and citrate of potash are probably the best for the 
purpose ; and they should be given in such quantities as to render the 
urine constantly alkaline. Dr. W. Roberts has shown that the alka- 
line carbonates slowly dissolve uric acid calculi, and that the urine 
may be rendered and kept sufficiently charged with carbonate to pro- 
duce this effect by administering to the adult forty or fifty grains of 
the acetate or citrate in 3 or 4 ozs. of water every three hours. And 
hence he recommends that, if there be reason to believe that uric acid 
calculi are present in the kidney, the patient should be submitted to 
this alkaline treatment. Phosphate of soda also dissolves uric acid, 
and Dr. Golding Bird recommends its use in scruple or half-drachm 
doses. It is important at the same time to have regard to the patient's 
mode and habits of life and to any morbid conditions which may be 
present. Thus, valuable indications for treatment may be furnished 
by the fact that he is a bon vivant or of sedentary habits, or that he 
suffers from indigestion or from gout. 

Cystin and xanthin deposits and calculi may be treated in the same 
manner as those of uric acid. 

Oxalate of lime, like uric acid, is generally deposited in acid urine, 
and indeed they are not unfrequently associated. Its presence in small 
quantities is often dependent on the use of certain articles of diet ; when 
it is more abundant and persists, the patient frequently suffers from 
more or less indigestion, or presents symptoms of mental depression. 
The direct treatment of oxaluria is not generally very efficacious. The 
patient's general health should be improved by tonic medicines and 
general tonic treatment, and by abstinence, so far as possible, from the 
use of vegetables containing oxalate of lime, and of sugar 4 and other 



HYDRONEPHROSIS. 



791 



substances which are readily convertible into oxalic acid. Nitro-muri- 
atic acid is often recommended ; while, on the other hand, alkalies seem 
to be sometimes efficacious. 

Persistent alkalinity of urine from the presence of the fixed alkalies 
is rare and in itself not very important. It generally seems to be 
associated with some degree of ill-health and cachexia, and may be 
taken to indicate the need of tonic treatment and of generous diet. 
Mineral acids, especially the nitro-muriatic, and perchloride of iron, 
are valuable remedies. 

Alkalinity from the presence of carbonate of ammonia is a much 
more serious matter. This always results from decomposition of the 
urine in the urinary channels, is indicative of cystitis or pyelitis, and 
necessarily leads to the deposition of crystalline phosphates. For the 
relief of this condition we must have recourse to the treatment recom- 
mended for cystitis. 



HYDRONEPHROSIS AND ATROPHY OF THE KIDNEY. 

Causation and Morbid Anatomy. — Whenever any permanent im- 
pediment to the flow of urine occurs — whether it be in the urethra, 
bladder, or ureter ; whether it be due to some calculous or other ob- 
stacle within ; or to some affection of the walls themselves, such as 
thickening and contraction, valvular folds, or paralysis; or to pressure 
from without, such as may be caused by ovarian or uterine tumors — 
the cavities above the seat of obstruction become dilated and their 
parietes thickened, and at the same time the kidney structure becomes 
expanded and attenuated. The condition known as hydronephrosis 
results. If complete obstruction takes place the secretion of urine con- 
tinues for a time, but its accumulation causes more and more distension 
of the renal cavity and more and more pressure on the renal structure, 
until at length the function of the latter ceases to be performed in any 
degree. In this case, equally with that in which pus accumulates, those 
portions of the renal cavity whose lining membrane is least resistant 
expand most ; and consequently, while the pelvis and infundibula are 
comparatively little altered, the calyces become dilated at the expense 
of the yielding and atrophying renal substance, until they form a series 
of subglobular cavities surrounded and separated from one another by 
atrophied renal structure, and communicating by separate and com- 
paratively small orifices with their respective infundibula. When the 
obstruction is partial, as well as during that period of total obstruction 
in which the renal elements are still secreting urine, this fluid changes 
in quality; it becomes less and less rich in solid constituents, pale, 
watery, and of low specific gravity, but remains for the most part 
devoid of albumen. Subsequently to the cessation of the proper 
urinary secretion, the fluid in the cavity may still increase in quantity 
and may still undergo changes. Thus in advanced hydronephrosis it 
is generally watery but still containing traces of the urinary solids ; it 
is often albuminous ; sometimes charged with decomposing blood ; 



792 



DISEASES OF THE GENITO - URINARY ORGANS. 



sometimes more or less glairy and colloidal ; and occasionally purulent. 
After a kidney has become completely hydronephrotic and ceases to 
secrete urine, various consequences may ensue. In some cases it re- 
mains for a long while almost stationary. In some the contents be- 
come slowly absorbed and the atrophied tissues shrink and indurate 
until at length a small, hard, tabulated cystic body, weighing perhaps 
from a drachm or two to half an ounce, remains. In other cases the 
dropsical kidney slowly enlarges until it forms a tumor several times 
the bulk of the healthy organ, and in some cases sufficiently large to 
fill at least one-half of the abdomen. It is important to know that 
hydronephrosis from total or partial, and often valvular, obstruction 
of the ureter is not unfrequently congenital, and hence that hydro- 
nephrotic tumors are not altogether uncommon in new-born babes and 
young children. 

Symptoms and Progress. — As a rule the changes above described 
occur (supposing no inflammation ensue) without producing symptoms, 
and without, therefore, calling for treatment. It is comparatively rare 
for the hydronephrotic kidney to become so large as to excite obser- 
vation, still more rare for it to become so large as to exert by its pres- 
sure on surrounding organs any deleterious influence. In these latter 
cases alone diagnosis is needed and indeed possible. The elements on 
which an accurate opinion must be based are the history of the case, 
the situation and relations of the tumor, its characters as to form, re- 
sistance, and fluctuation, and the constitutional symptoms which are 
associated with it. In addition to these there is a symptom of rare 
occurrence, but very characteristic when it does occur, and peculiar to 
cases of incomplete obstruction, namely, the occasional rapid but tem- 
porary subsidence of the tumor, attended with a sudden increase in the 
quantity of urine passed, and some change in its quality. In some 
cases the dilated organ suppurates, and a renal abscess with the usual 
symptoms of that condition supervene. 

A hydronephrotic tumor is liable to be confounded with carcinoma 
and hydatids of the kidney or of neighboring parts, and with ovarian 
cysts. It is rarely fatal, except in those cases in which it is double, 
or where it is associated with other maladies, or where, from its bulk 
and interference with other organs, or from suppuration, slow exhaus- 
tion ensues. 

Treatment. — The treatment is entirely surgical. If manipulation 
fail to drive the contents into the bladder, paracentesis may become 
necessary. To prevent danger from escape of fluid into the perito- 
neum, this operation should be performed behind the line of colon 
which crosses the tumor. 



MISPLACED AND MOVABLE OR FLOATING KIDNEYS. 

Causation and Morbid Anatomy. — Misplacements of the kidneys are 
chiefly important in relation to the diagnosis of abdominal tumors. 
Sometimes, as a congenital peculiarity, one or both kidneys, instead of 



CHYLURIA. 



793 



occupying their normal position, lie upon the brim of the pelvis. 
Sometimes one, or both of them, though otherwise normally placed, 
are attached to the lumbar region by a peritoneal duplicative or meso- 
nephron analogous to the mesentery, or lie freely movable in the lax 
retroperitoneal connective tissue which surrounds them. Mobility of 
the kidney is said to be much more common in women than in men, 
and on the right than on the left side. Its cause is obscure. It may 
perhaps be, in some cases, a congenital defect, but it seems also occa- 
sionally to follow upon parturition, and possibly then to be connected 
with that general laxity of the abdominal parietes which parturition 
causes. 

Symptoms. — The floating kidney projects more than natural (assum- 
ing an oblique position, with the upper end pointing forwards and in- 
wards), and is freely movable within narrow limits under the abdominal 
parietes. The organ may usually be perceived somewhere in the hypo- 
chondriac or umbilical region, between the umbilicus and the cartilages 
of the ribs, and, if on the right side, is apt to make its appearance just 
below the liver, and to be mistaken for an hepatic tumor. If it be 
grasped, as it sometimes can be, a sickening sensation is produced, 
similar to that which results from squeezing the opposite loin, and 
sometimes a distinct falling in of the corresponding lumbar region, with 
increase of resonance, may be clearly recognized. From its pendulous 
condition it is apt to get compressed or otherwise injured, and, conse- 
quently, to become more or less painful, tender, and swollen. 

It must be added that there is still considerable doubt on the part 
of many with respect to the occurrence of floating kidney. It is cer- 
tain that there is little post-mortem evidence in its favor, and that 
uterine, fibroid, and other tumors have been mistaken by competent 
observers for floating kidneys. On the other hand, it must be borne 
in mind that such kidneys are not a cause of death. 

Treatment. — When a movable kidney is painful, rest, local applica- 
tions, and the internal use of sedatives may be requisite. To protect 
it from injury, and at the same time to replace it to some extent, an 
abdominal belt may be worn, with a concave pad beneath it, adjusted 
to the form and position of the kidney. 



CHYLURIA. {Chylous Urine.) 

Causation and Symptoms. — This affection was first recognized and 
described by Dr. Prout, but since his time has been pretty frequently 
met with and investigated by other observers. It is characterized for 
the most part by the occasional or continuous discharge of urine, which 
is milky when passed, coagulates on standing into a tremulous mass 
resembling blanc-mange, and then, becoming again liquefied, furnishes 
a creamy scum and a pinkish or brownish sediment. The urine has, 
in fact, exactly those characters which would result from the admix- 
ture, in various proportions, of normal urine and normal chyle. It 



794 



DISEASES OF THE GENITO- URINARY ORGANS. 



presents the ordinary urinary constituents, but in diminished propor- 
tion to the whole bulk of fluid ; and it contains also fibrin, the pres- 
ence of which explains its spontaneous coagulability; albumen, as may 
be shown by the usual tests ; fat in a molecular form, like the fat of 
chyle, the presence of which accounts for the milky character of the 
fluid when passed, and for the creamy scum ; occasionally a small 
proportion of red corpuscles, to which the colored sediment is thus in 
part attributable ; and leucocytes. No casts, however, have ever been 
detected in it, or other evidence that the chylous material comes from 
the kidney. Further, it often happens in these cases that the urine 
which is passed is not milky, although probably presenting in all 
other respects the peculiarities which have been enumerated. It is, in 
fact, lymphous, and not chylous ; there is no fat, and the coagulum is 
transparent like ordinary calves'-foot jelly. The presence of fat is, in 
some instances, observed mainly in the morning's urine ; more com- 
monly it chiefly characterizes the urine which is passed shortly after 
meals. 

Cases of chyluria appear to be much more common in tropical than 
in temperate climates, more frequent in adults than in children, in 
females than in the opposite sex. 

The affection manifests itself, for the most part, suddenly, is liable 
to intermissions, and occasionally, after lasting some time, disappears 
for years or even for life. It is attended with no special symptoms, 
except such as may result from the continuous drain of nutrient fluid, 
and those which are connected with the condition of the urine and the 
urinary organs, and its presence is compatible with apparent good 
health and even with long life. The characters which the urine pre- 
sents have already been described; it may be added that chylous urine 
not unfrequently coagulates in the bladder, causing more or less dis- 
comfort, and the discharge of coagulated material. 

Pathology. — Dr. Prout attributed the disorder to a combination of 
two circumstances ; one a defect of assimilation which permitted chyle 
to mingle with the blood without being converted into blood, the other 
some renal default, in consequence of which the unchanged chyle was 
permitted to transude through the kidneys. But the blood has been 
examined in cases of chyluria without the detection of anything ab- 
normal in it ; and not only, as has been already stated, is there no 
evidence during life to show that the kidneys themselves are diseased, 
but post-mortem examination equally fails to detect any morbid change 
in them. 

Dr. W. Roberts, basing his views partly on a case recorded by him- 
self, and partly on one published by Dr. Vandyke Carter, suggests an 
explanation of the phenomena of chyluria which will probably prove 
to be correct for at least many cases. In these two cases there was 
chyluria, but there was also, in the usual situation, namely, on the 
lower part of the abdomen and in the scrotum, enlargement of lym- 
phatic vessels, with vesicular dilatations, which when ruptured yielded 
abundance of lymph or chyle — exactly the same kind of fluid as that 
which was passed with the urine. In Dr. Carter's patient, the dis- 
charge of chyle from the urinary organs and that from the skin alter- 



HEMATURIA. 



795 



nated. Dr. Roberts contends that in these cases the chyle in the urine 
and that yielded by the skin were derived from a common source, 
namely, rupture of vesicular dilatations of lymphatic vessels situated 
on the one hand in the mucous surface of the bladder or that of some 
other part of the urinary tract, on the other hand, at the cutaneous sur- 
face ; and he argues thence that chyluria generally depends on a similar 
lymphatic affection of the mucous membrane of the urinary tract. The 
disease, in fact, from this point of view, is identical with what has been 
described earlier in this volume under the name of elephantiasis lym- 
phangiectodes. 

Dr. Lewis has recently described a small round naematoid worm, 
about 7 ] g inch long, which appears to be not uncommon in India, as 
occurring in the blood and urine. They are sometimes present in vast 
numbers, and are often associated with the presence of chyluria. This 
connection, however, is probably entirely fortuitous. 

Treatment. — It is needless to enumerate all the remedies which have 
been employed in the treatment of chyluria ; nothing appears to have 
ever been really efficacious, and it is clear, if the explanation above 
given be correct, that nothing, except perhaps rest and astringents 
locally applied, is likely to be efficacious. Tonics may be needed in 
the ansemia which is apt to come on in the course of chyluria. 



HEMATURIA. 

Causation and Symptoms. — The presence of blood in the urine may 
be due to many different circumstances, but these have been already 
discussed in sufficient detail, and need not be further considered now. 

It is not always possible to ascertain the source or the cause of 
hematuria. It may, however, be observed that, if it take place from 
the substance of the kidney, it will almost always be attended with the 
presence of blood-casts, and the urine will generally be more or less 
smoky ; that, if it take place from any of the urinary passages, no 
casts will be present ; and that if it be derived from the bladder or 
urethra, pure unmixed blood will probably be occasionally passed, 
either at the commencement or at the end of micturition, or at other 
times. Further, the more abundant the blood is, and the more it ex- 
hibits the ordinary characters of blood, and tends to coagulate, the 
more likely is it to have been yielded by the urinary passages. The 
haemorrhage which attends simple congestion or inflammation of the 
kidneys or urinary channels is generally scanty. The most profuse 
haemorrhages are usually due to villous or malignant growths of the 
bladder or kidney, or to the effects of renal or vesical calculi. Profuse 
haemorrhage is said also to occur vicariously of menstruation. We 
have previously described the appearance which the urine presents 
when mixed with blood ; and we must refer the reader to other parts 
of this section for an account of the lesions of the urinary organs liable 



796 



DISEASES OF THE GENITO -URINARY ORGANS. 



to be attended with haemorrhage, and for the means by which their re- 
spective haemorrhages may be distinguished. 

Treatment. — When the discharge of blood with the urine is scanty 
and of temporary duration, the loss in itself is a matter of little im- 
portance, and no special anti-hsemorrhagic treatment is needed. But 
persistent small haemorrhages, as well as occasional profuse haemor- 
rhages require if possible to be arrested. The patient should be placed 
in the recumbent position, and kept perfectly quiet and cool. He 
should have ice to suck, or be supplied with cold drinks in small quan- 
tities. In addition, it is advisable to give by the mouth some form of 
astringent medicine, either turpentine, gallic acid, or other vegetable 
astringent, lead, perchloride of iron, some mineral acid, or digitalis. 
If there be reason to believe that the bleeding is taking place from the 
kidney, ice or cold compresses may be applied to the loins; if from the 
.bladder similar applications may be made to the perineum or hypo- 
gastrium, and either cold water, or solutions of perchloride of iron or 
tannic acid may be injected into the bladder. 



PAROXYSMAL HEMATURIA. 

This is a remarkable affection, which was first distinctly described 
a few years since by Dr. G. Harley, and of which many cases have 
since been recorded. It is characterized by the occurrence, at more or 
less irregular intervals, of sudden attacks of severe rigors, followed by 
the discharge from the kidneys of urine loaded with blood; the patient's 
health between successive attacks being apparently perfectly good, or 
at all events not seriously impaired. 

Causation. — Paroxysmal haematuria has hitherto been observed 
almost exclusively in males and in such as are of adult age. A few of 
those who have suffered from it have previously had ague ; but with 
this exception the patients have, apart from their renal affection, en- 
joyed good health, and have been apparently quite free from malarious 
taint. In all cases the onset of the disease is sudden, and almost 
without exception distinctly traceable to exposure to cold or draughts. 

Symptoms and Progress. — The patient, immediately after or even 
in the course of exposure, begins to complain of chilliness and uneasi- 
ness across the loins : the latter condition speedily passing into more or 
less severe aching, the former into an extreme sense of general cold, 
attended with pallor or duskiness of surface, shrinking of the skin, and 
severe rigors ; together with which symptoms there may be weakness, 
stiffness or aching in the limbs, yawning, nausea, and vomiting, and 
retraction of the testicles. During this time the temperature is lowered, 
and often by as much as two or three degrees. After the patient has 
been in this condition for half an hour, or it may be an hour or two, 
he is astonished to find on passing his water that this fluid is exceed- 
ingly dark-colored and turbid; not unfrequently resembling porter. 
The general symptoms now speedily abate, and the patient, after a 



PAROXYSMAL HEMATURIA. 



797 



little reactionary rise of temperature, but no sweating stage, appears at 
the end of a few hours to be perfectly well. The urine gradually loses 
its specific characters, and a little later, perhaps, than the patient's ap- 
parent restoration to health resumes its normal condition. The porter- 
like urine, which is generally faintly acid and is of very various density, 
deposits an abundant grumous sediment, and contains a large quantity 
of albumen, together with granular and. hyaline casts, and often crystals 
of oxalate of lime, but in the place of blood-corpuscles (which are de- 
tected rarely and in small numbers) presents abundant brownish 
granular matter, which is supposed to be due to the disintegration of 
these bodies. [Hence the disease is more properly called hsematinuria.] 
The onset of subsequent attacks is equally sudden with that of the 
first, and the succession of events exactly repeated in them. Moreover, 
these later attacks are generally, like the first, distinctly traceable to 
the influence of cold: the slightest draught or the slightest chill being 
in many cases competent to evoke them. In some instances the parox- 
ysms recur with almost ague-like periodicity ; more generally, however, 
they come on at irregular intervals. Sometimes patients suffer from 
them once or twice a day, sometimes once or twice a week, sometimes 
at longer intervals, and sometimes they lose their liability to them 
during warm weather. With such variations the disease may last for 
years, generally, too, without inducing any serious consequences either 
as respects the condition of the kidneys themselves or the general 
health. The patient often, however, becomes, as might be supposed, 
ansemic, languid, and weak. 

* Pathology. — The pathology of paroxysmal hematuria is somewhat 
obscure. It has been supposed to have some relation with ague, with 
oxaluria, with rheumatism. It has been regarded, on the one hand, 
as an affection of the kidney, on the other as an affection of the blood. 
But, whatever view be ultimately adopted, there are certain facts 
which stand out clearly ; these are : first, the dependence of the parox- 
ysm on a cutaneous chill ; second, the intense congestion of the kidney 
which attends the paroxysm ; third, the relief of both congestion and 
paroxysm by a copious discharge of blood ; and fourth, the indepen- 
dence of all these conditions of any structural disease of the kidney. 
The phenomena of the disease, indeed, are probably due to an influence 
transmitted from the skin to the vaso- motor nerves of the kidney, in 
virtue of which the small vessels of this organ are stimulated into a 
temporary condition of active dilatation. 

[The American student must be careful not to confound this disease 
with one of the many results of malarial poisoning occasionally met 
with in portions of the Southern States, and characterized by jaundice, 
great irritability of the stomach, giving rise to uncontrollable vomit- 
ing, and a peculiar alteration in the color of the urine, generally attrib- 
uted by Southern physicians to the presence of blood. M. Berenger 
Feraud, who has studied the disease in Senegambia, has arrived at a 
different conclusion, holding that the foreign body to which the urine 
really owes its remarkable appearance is bile, having been able to find 
blood-corpuscles or haBmatin in only a very small proportion of the 
cases. He therefore prefers to call it melanuric bilious fever of warm 



798 



DISEASES OF THE GENI TO-URINARY ORGANS. 



climates. It generally yields to anti-periodic doses of quinia — a 
remedy which has no power to prevent the attacks in paroxysmal 
hsematinuria,] 

Treatment. — Many remedies have been employed, but none with 
any striking success : quinine and arsenic, on the ground of the perio- 
dicity which the disease presents ; iron because of the patient's anaemic 
state ; perchloride of iron, gallic acid, and lead for their styptic proper- 
ties ; and digitalis and ergot of rye on account of their influence in 
contracting the arterioles. The most important treatment, however, is 
the prophylactic ; during the paroxysm the patient should be placed in 
bed and kept warm ; and at other times he should be cased in flannel 
and otherwise warmly clad, his feet and loins especially should be pro- 
tected, and he should carefully avoid all exposure to draughts, all 
loitering in the cold, and riding in cold weather in an open vehicle. 



DIABETES. (Diabetes Mellitus. Glycosuria.) 

The most striking phenomenon of this disease is the secretion of 
urine containing a greater or less amount of glucose or grape-sugar. 
It is not, however, every one whose urine contains glucose who can be 
said to suffer from diabetes. For it has been shown that this sub- 
stance may be present in the urine temporarily or in small quantities 
in many affections involving hepatic congestion, such as injuries or 
organic lesions of the liver, obstructive cardiac and pulmonary com- 
plaints, and certain affections of the central nervous organs, and also 
under the influence of certain articles of diet ; while none of the other 
special phenomena of diabetes are either present or tend to become 
developed. 

Causation. — The cause of diabetes is not known. It is certainly in 
some cases hereditary ; it occurs at all ages, from infancy up to old age, 
and in both sexes, though about twice as frequently in the male as in 
the female. Its advent has been attributed to exposure, to habits of 
life, to injuries of various kinds, and to mental disturbance. In many 
cases, however, no cause whatever can be assigned or suggested. 

Symptoms and Progress. — Diabetes, for the most part, comes on 
insidiously. The patient observes that he has been for some time 
passing more and more urine daily, that he has been unusually thirsty, 
that his appetite has been getting voracious, and yet that he has been 
losing flesh and strength. Occasionally it happens that he is also, and 
possibly first, struck by some peculiarities in his urine dependent on 
the presence of sugar in it. He finds that when drops of it fall upon 
his trousers or boots, a whitish powdery film is left on their evaporation, 
or that flies, bees, or other insects are attracted to the contents of his 
chamber-pot, or to surfaces on or against which he has emptied his 
bladder. The prominent features of the disease are comprised in the 
above brief sketch ; they are the secretion of an excessive quantity of 
urine loaded with glucose, intense thirst, voracious appetite, together 



DIABETES. 



799 



with progressive emaciation and debility, followed after a longer or 
shorter time by death. These symptoms, however, present a good deal 
of variety, and many others of more or less importance are generally 
associated with them. We will discuss them seriatim. 

The quantity of urine secreted is generally considerably larger than 
natural ; so that the patient not only micturates frequently during the 
day, but is compelled to rise from his bed several times in the course of 
the night in order to relieve himself. The quantity depends, of course, 
mainly upon the quantity of fluid which he drinks, and varies therefore 
largely. Sometimes it is little more than normal, but generally it 
averages between six and twelve pints daily, and occasionally rises to 
twenty, thirty, or more. Its color is usually pale yellow; it is acid, 
clear and free from sediment, and has a peculiar odor which has been 
likened to that of new milk, apples, or hay. Its specific gravity, not- 
withstanding the large quantity which is passed, is always abnormally 
high. It is rarely below 1035, often rises to 1045 or 1050, not unfre- 
quently reaches 1060, and is said to have exceeded 1070. The cause 
of this density of the urine is the presence in it of an abnormally large 
proportion of solid constituents. As a rule, considerably more urea is 
discharged daily by diabetic than by healthy persons, but the amount of 
urea is usually very small in proportion to the quantity of fluid in which 
it is dissolved. The increase of specific gravity, therefore, is not due to 
that ingredient. It depends, indeed, almost entirely upon the sugar. 
The quantity of this varies of course considerably; but it generally 
forms from eight to twelve per cent, of the urine, and ranges daily from 
fifteen to twenty-five ounces. Its amount may, however, be much less 
than this, and also much greater. The quantity of sugar excreted is 
greatest after meals, and is always largely increased after the ingestion 
of sugar or starchy food; under opposite circumstances it diminishes, 
and it may disappear absolutely if the diet be restricted to nitrogenous 
substances. Sometimes, under the influence of inflammatory affections, 
and again towards the close of the disease, the urine diminishes both 
in quantity and specific gravity, and its sugar diminishes or fails ; 
sometimes it becomes albuminous, and hyaline casts may be found in 
it. Dependent in some degree on the irritant effects of the urine, the 
urethral orifice in the male, or the vulva in the female, becomes red 
and irritable, and even excoriated or eczematous. The sexual appetite 
is sometimes augmented in the beginning, but both that and virile 
power diminish before long, and then disappear. 

One of the most distressing symptoms of which diabetic patients 
complain is extreme thirst, and it is one of the first symptoms to make 
its appearance. The appetite, too, is generally excessive, sometimes 
ravenous. This, however, is subject to considerable variation. Some- 
times it is no greater than natural, sometimes it is greatly impaired, 
and there may be nausea and absolute loathing of food. The latter 
conditions often come on towards the termination of the case. The 
mouth, fauces, and tongue are usually dry, clammy, and morbidly red. 
The gums not unfrequently retreat from the teeth, and the latter be- 
come loose and apt to fall out. The patient often complains of uneasi- 
ness or sinking at the epigastrium. The bowels are usually constipated, 



800 



DISEASES OF THE GENITO -URINARY ORGANS. 



the motions being scanty and dry; but occasionally, and not unfre- 
quently ushering in the fatal event, dysenteric diarrhoea supervenes. 

The skin of diabetic patients is almost always dry and harsh, though 
occasionally slight perspirations occur, and some patients perspire freely. 
There is not unfrequently a tendency to itching; and various eruptions, 
especially eczema, psoriasis, and boils, are said to be of common occur- | 
rence. The hair sometimes falls out. The skin, or rather perhaps the 
patient generally, yields an unpleasant odor, like that which belongs 
to his urine. 

The symptoms referable to the heart and lungs are those only which 
usually attend wasting disease, namely, increasing feebleness with aug- 
mented rapidity of the pulse, and more or less shortness of breath, 
especially on exertion. The blood of diabetic patients contains glucose, 
of which as much as .3 to .5 per cent, has been detected by analysis. 

Nervous phenomena of various kinds usually manifest themselves 
in the course of the disease. The patient becomes apathetic, morose 
or taciturn, or irritable, or towards the close drowsy or comatose. In- 
sanity sometimes supervenes ; and occasionally various forms of hyper- 
esthesia, loss of motor power, and the like. Impairment of vision also 
is a common attendant on the progress of this disease; in some cases 
the patient simply loses the power of adjusting his eyes for near vision, 
he becomes prematurely presbyopic ; in other cases he suffers from am- 
blyopia; in others, again, soft cataract forms in one, or more commonly 
in both eyes. 

But, besides all the above phenomena, others come on which are not 
so much referable to any one organ as to general impairment of nutri- 
tion and advancing debility of the system generally. There is great 
susceptibility to external cold. A sort of hectic condition arises, and 
occasionally there may be some febrile elevation of temperature; gen- 
erally, however, the temperature remains about normal or even a little 
below the normal. Emaciation is almost constant ; the fat disappears, 
the muscles shrink, the frame becomes attenuated, the skin appears 
tightly drawn over the forehead and other parts of the face, and is 
thrown into fine wrinkles when expressional and other movements of 
the facial muscles are executed. Occasionally, on the other hand, and 
more particularly in elderly persons, the tissues remain overloaded with 
fat to the end. Towards the close of the disease it is common to meet 
with anasarca, which is generally limited to the lower extremities. 
And not very unfrequently gangrene takes place in the fingers or toes 
or more extensive portions of the extremities, in the genitals, nose, 
ears, or other parts. 

Another complication which is at least as common as any of the 
above, and on the whole of far more importance, is pulmonary phthisis. 
This attacks a very large proportion of diabetic patients ; and indeed 
of patients who die of diabetes probably one half suffer from it. The 
affection is rarely, if ever, in the form of miliary tuberculosis, but 
almost invariably in that of caseous consolidation, with tendency to 
disintegration and the formation of cavities. 

In some cases the progress of diabetes is exceedingly acute and 
rapid. Death has resulted from it after an illness of two or three 



DIABETES. 



801 



weeks only. Again, death may be delayed for ten years or more. For 
the most part, however, the patient succumbs in from one to three 
years. Recovery is exceedingly rare. The cause of death is usually 
asthenia, hastened in some cases by gangrene, dysentery, or phthisis; 
but not unfrequently the patient dies comatose. It must be added 
that diabetic patients bear fatigue, mental or bodily, very badly, and 
that at an advanced period of their disease they are apt, after such 
fatigue, to fall into a state of almost sudden collapse, from which they 
do not rally. 

The above remarks apply to the usual form of the disease, to which 
indeed our description has hitherto been exclusively limited. It 
must be stated, however, that not unfrequently, in elderly persons and 
especially in such as are gouty, the urine contains sugar, it may be in 
large quantities, and yet few or none of the other symptoms of diabetes 
are present. The glycosuria under such circumstances may persist for 
years, either uniformly or with remissions, the patient perhaps pass- 
ing at times more water than natural, and suffering more or less from 
dyspepsia, yet presenting no emaciation and no serious impairment of 
strength, and ultimately recovering, or dying, not of diabetes or of its 
ordinary complications, but of some independent disease. 

Iforbid Anatomy and Pathology. — Morbid anatomy reveals little as 
to the nature and processes of diabetes. Excluding dysenteric affec- 
tion of the bowels, gangrene of various parts, pulmonary tuberculosis, 
and cataract (which are not present in all cases, and present no dis- 
tinctive characters), but little remains for description. The kidneys are 
generally enlarged and more or less congested, and the epithelial lining 
of the tubules is occasionally in a distinctly fatty condition. The 
liver and other chylopoietic viscera to which, on theoretical grounds, 
attention should be mainly directed, present no constant lesions. The 
former has occasionally been found cirrhotic, the latter inflamed ; but 
far more commonly all appear healthy. The nervous system, again, 
has been examined with care, on account of the influence which certain 
parts of it have in causing glycosuria. Tubercular and other tumors 
have been occasionally discovered in the neighborhood of the fourth 
ventricle ; and Dr. Dickinson has recently drawn attention to the ex- 
istence of small cavities, visible sometimes to the naked eye, originat- 
ing in softening and degeneration of the tissue around some of the 
smaller arteries, and containing, when fully formed, simply serous 
contents. He has found them in most parts of the central nervous 
organs, but more particularly in the olivary bodies, in the median 
plane of the medulla oblongata, and in the gray matter in the floor of 
the fourth ventricle. 

If the pathology of diabetes has not been completely elucidated, it 
has at all events had much light thrown upon it during the last few 
years by the labors of Bernard and other investigators. It has been 
proved that the liver, besides manufacturing bile, is also an organ for 
the conversion of albuminous and starchy matters (mainly if not en- 
tirely those obtained from the food) into dextrin or glycogen — a 
starchy substance which exists in large quantities in the liver, and is 
readily convertible by ferments, and among others by a peculiar albu- 

51 



802 



DISEASES OF THE GENITO -URINARY ORGANS. 



minous ferment existing in the blood but not yet separated from it, 
into glucose, or grape-sugar. It is probable even that the healthy 
liver converts sugar itself into glycogen, and that hence the liver, 
amongst other duties, opposes a barrier to the admixture of saccharine 
ingesta with the blood. What becomes of this glycogen, which is 
found in the liver and accumulates in it, we need not stop to consider. 
It is certain, however, that in health neither it nor glucose is dis- 
covered in the blood. Further, experiments made by Bernard, Schiff, 
and others have demonstrated the important influence which the 
nervous system exerts over the glycogenic function of the liver. It 
has been proved that by irritating various parts of the central nervous 
organs artificial diabetes may be induced — irritation of the floor of the 
fourth ventricle, particularly of a spot in it midway between the origins 
of the auditory nerves and par vagum, being especially efficacious in 
this respect. There is reason to believe that this spot is either the 
origin of, or in relation with, the tracts of sympathetic nerves which 
regulate the diameter of the hepatic vessels; and that through the 
agency of these nerves the vessels of the liver become actively dilated, 
upon which phenomenon congestion and glycosuria supervene. Schiff, 
by dividing the anterior columns of the cervical cord through which 
the sympathetic tracts above referred to pass en route to the liver, also 
produces glycosuria; which, again, is probably dependent on dilatation 
of the hepatic vessels and hypersemia, but dependent upon dilatation 
of paralytic origin, and which, like the diabetes it causes, is of com- 
paratively long duration. Experiment would therefore seem to show 
that diabetes depends on dilatation of the hepatic vessels, with accu- 
mulation of blood in them and rapid flow of blood through them, and 
consequently increased or rather modified functional activity of the 
liver ; and that the dilatation may be either active, the result of irrita- 
tion of nerves, producing for the most part a temporary condition of 
diabetes ; or passive, the result of paralytic dilatation, inducing as a 
rule a chronic form of glycosuria. The dependence of diabetes on 
hyperemia of the liver has been demonstrated by other experiments in 
which hyperemia has been produced without the intervention of the 
nervous system ; and is confirmed by the not unfrequent dependence 
of some degree of the affection on pathological congestion of the liver 
arising from cardiac or pulmonary disease, from injuries to the liver, 
and from inflammations involving it. According to these views, 
which, it may be remarked, only partially explain the dependence of 
diabetes on hepatic derangement, the occasional and temporary impreg- 
nation of the urine with sugar would seem to have an irritative, the 
typical forms of diabetes a paralytic, origin. 

Treatment. — The treatment of diabetes is a subject of great interest, 
and has been regarded and conducted from all points of view with 
varying degrees of success. As with most other diseases, some cases 
of it are so serious from the beginning and so rapidly fatal, that all 
efforts to arrest their progress are futile, while some cases are so slightly 
pronounced that the jmtient either remains in fair health in spite of 
his sugarv urine, or appears to derive benefit from almost any treatment. 
Between these extremes lie the great majority of cases, which if not 



DIABETES. 



803 



admitting of cure, undoubtedly often admit of important alleviation by 
appropriate treatment. It may be at once stated that the use of blisters 
and other local applications to the head or to the liver has been advo- 
cated and practiced by various physicians, on the ground that one or 
other of these organs was at fault; and beneficial results have been 
recorded. Further, we may at once point out the importance of gener- 
ally promoting the functions of the skin by warm baths and warm 
clothing ; of maintaining the regular action of the bowels ; of alleviat- 
ing, arresting, or curing dysentery and the other complications which 
so frequently attend the progress of diabetes; of preventing all unneces- 
sary fatigue; and generally of putting the patient under those external 
conditions which are commonly regarded as being conducive to health. 

The most important point, perhaps, in the treatment of diabetes is 
the regulation of the patient's diet. It has long been proved that the 
abstention from sugar and from those other articles of food which are 
most readily convertible into sugar is always attended with a marked 
diminution in the quantity of sugar voided, in the specific gravity of 
the urine, and in the amount of that fluid secreted ; and that in a very 
large proportion of diabetic patients there is at the same time gain of 
flesh with manifest improvement of health. For these reasons it is 
customary to debar the patient from certain alimentary matters, espe- 
cially sugar in all forms, and all vegetable articles whose nutritious 
qualities depend on sugar, starch, or related matters— among which 
may be enumerated bread, potatoes, rice, sago, tapioca, peas, beans, 
turnips, parsnips, carrots, and most fruits. There is good reason also 
to believe that alcohol in all its forms is pernicious. Among the foods 
which are permissible are : first, the green vegetables ; second, all sorts 
of animal food, including milk, eggs, cheese, and butter; and, thirdly, 
tea and coffee without sugar. It is found, however, in practice almost 
impossible to overcome the craving for bread or some equivalent for 
bread which soon arises under the use of a restricted diet. Various sub- 
stitutes have been suggested and may be used temporarily; the most 
important of these are gluten bread, bran-cake, and almond biscuits or 
rusks, to which may be added (as being more palatable, though more 
objectionable) toast uniformly and deeply browned. Lately Dr. Donkin 
has strongly advocated the administration of skim milk, to the exclu- 
sion of all other articles of diet. He gives from six to eight pints daily 
to an adult. And it is certain that many patients become after a little 
time fairly reconciled to the diet, that they often gain strength and flesh 
under its use, and that at the same time the urine diminishes in quan- 
tity, in density, and in the amount of sugar it contains. 

It has often been held important to restrain the patient from grati- 
fying his intense craving for drink. It is cruel, however, to put such 
restraint upon him, and of very doubtful benefit. Acidulated drinks 
are said to be specially useful in assuaging his thirst, and, above all, 
dilute solutions of phosphoric acid. 

Of all drugs, opium seems to be the most efficacious. It has long 
been esteemed in the treatment of diabetes, and Dr. Pavy especially has 
latterly extolled its virtues. Diabetic patients are said to be little sus- 
ceptible of the influence of opium, and may therefore take it with safety 



804 



DISEASES OF THE GENITO - URINARY ORGANS. 



in comparatively large quantities. It is best, however, to commence 
with small closes, say half a grain, of the powder, three times a clay, 
and gradually to augment them, according to their effect until each 
dose is raised to five or six grains. A fair number of cases have been 
t recorded in which great amelioration, if not absolute cure, has followed 
this treatment. Still more recently Dr. Pavy has employed, and ap- 
parently with considerable success, codeia, in doses commencing at about 
half a grain, three times a day, and gradually increasing to two or three 
grains. 

Again, alkalies — bicarbonates, acetates, citrates — have been regarded 
as valuable remedies; as also has the hot or vapor bath. Iron and 
other tonics are sometimes beneficial. [Other remedies which have been 
employed with more or less success are lactic acid, rennet, and yeast.] 

As respects the treatment of the masked diabetes of elderly people, 
it is impossible to lay down definite rules. It is generally needless to 
carry out the plans of treatment recommended above, at any rate to 
carry them out strictly or continuously. 



DIURESIS. [Diabetes Insipidus.) 

Under these titles are grouped a number of cases, which are linked 
together and characterized by the presence of extreme thirst and the 
secretion of a large quantity of pale limpid urine, free from sugar, and 
of low specific gravity. 

Causation. — Diabetes insipidus, which is very rare, appears to occur 
at any age and in either sex. The causes to which it has been attrib- 
uted are various. Among them may be mentioned tuberculosis, dis- 
eases of the brain, drink, accident, and exposure. It has, according to 
Trousseau and some others, a close affinity with diabetes mellitus, not 
only in symptoms but in the facts that there is a hereditary connection 
between them, and that the former is occasionally a sequela of the lat- 
ter. Bernard, moreover, has shown that diabetes insipidus, as well as 
glycosuria, can be produced by irritation of the floor of the fourth 
ventricle. 

Symptoms and Progress. — This affection sometimes comes on insidi- 
ously, sometimes quite suddenly. Its chief symptoms are the follow- 
ing : First, the secretion of large quantities of urine. The quantity 
passed is often considerably larger than is passed in saccharine diabetes. 
It may be as much as 20, 30, or 40 pints daily, or even twice as much. 
The urine is pale, watery, of very low specific gravity (often not above 
1002, 1003, or 1004), containing no sugar or other abnormal ingredient. 
Second, extreme thirst. This is proportionate to the diuresis, the quan- 
tity of fluid drunk being equal or nearly so to the quantity eliminated. 

Other symptoms vary. In some cases the patient appears to be well 
in all other respects, and, except for the continued presence of his in- 
firmity, enjoys life, and probably attains old age. In some cases he 
presents all the usual indications of diabetes mellitus ; he has a vora- 



SUPPRESSION OF URINE. 



805 



cious appetite, a parched mouth, and dry skin ; he becomes anaemic, 
sallow, emaciated, and weak ; and after a longer or shorter time dies as 
ordinary diabetics die. In other cases, again, diabetes insipidus is 
from its commencement associated with the presence of tuberculosis 
and other lesions. 

Morbid Anatomy. — In a few cases which have been collected by Dr. 
W. Roberts, the morbid anatomy of diabetes insipidus is illustrated. 
There is little, however, in the recorded post-mortem examinations to 
throw light on the nature of the affection. In several of the cases the 
kidneys were atrophied, and in one atrophied in connection with hydro- 
nephrosis. There is some reason to suspect that in these the primary 
affection was renal. In others the kidneys were healthy, as also were 
they in a case which died under our own care. In this case, as in one 
of Dr. Roberts's, the patient suffered from tuberculosis, which probably 
caused death. Here undoubtedly the diuresis was symptomatic only. 

Treatment — But little can be said about the treatment of diabetes 
insipidus. Various remedies, including tonics and regulation of diet, 
have been tried. Trousseau and Raver strongly recommend valerian 
in large doses. The former commences with two or three drachms of 
the extract daily, and gradually pushes the treatment until the daily 
portion reaches an ounce. Baths are sometimes beneficial. The con- 
stant galvanic current, passed between the loins and epigastrium, has 
recently been tried by Dr. M. Seidel. [Cases are reported in which 
recovery followed the long-continued use of the extract of ergot and 
tannic acid given in large doses. In one case at least a permanent 
cure was affected by ergot.] 



SUPPRESSION OF URINE. {Ischuria Renalis.) 

1. Functional Swpjjression of Urine. — More or less complete suppres- 
sion of the urinary secretion, lasting for a longer or shorter period, is 
of not unfrequent occurrence in the course of many different diseases or 
morbid conditions, among which may be especially enumerated malig- 
nant cholera, certain of the infectious fevers, acute enteritis, inflamma- 
tory affections of the kidneys, collapse, and hysteria. In many such 
cases the retention is symptomatic and temporary only, and probably 
scarcely affects the patient injuriously; in others the retention of urea 
and other effete nitrogenous matters in the blood which attends the 
suppression induces or aggravates typhoid phenomena and thus hastens 
death. It is remarkable, however, how in some cases, and more espe- 
cially in cases of hysteria, the urine continues for many weeks at a 
time in almost complete abeyance — the patient going, perhaps, for two 
or three days at a time without secreting any, and then perhaps passing 
only an ounce or two in the course of the twenty-four hours — and yet 
the patient remains wholly free from evidence of uramiic poisoning. 
These several cases of suppression are considered elsewhere in connec- 
tion with the diseases in which they occur, and need not further detain 
us now. 



806 DISEASES OF THE GENITO - URINARY ORGANS. 



2. Suppression of Urine from Obstruction. — Another class of cases 
of so-called " suppression " is that in which the failure to secrete urine 
depeuds on the existence of some mechanical obstacle to the escape of 
urine, situated either in the pelvis of the kidney or, as is far more 
common, in some part of the ureter. The permanent obstruction of 
one ureter, its fellow remaining pervious, is, as we have already shown, 
a not uncommon accident, and on the one hand results in the produc- 
tion of hydronephrosis with the ultimate wasting of the corresponding 
kidney, and on the other hand leads to increased functional activity of 
the opposite organ, which henceforth does the work of both. Obstruc- 
tion of the ureter is most commonly due to the impaction of a calculus 
in it, and hence it is not altogether remarkable that a person who has 
had one ureter blocked up and one kidney destroyed should be liable 
to the occurrence at some future time of the same accident on the 
opposite side. And indeed it is generally in cases of this sort that 
mechanical suppression occurs. 

Symptoms and Progress. — The suppression of urine under these cir- 
cumstances comes on suddenly. Sometimes it is, and remains, abso- 
lute; perhaps more frequently a little urine of low specific gravity, and 
containing little urea, is still passed at irregular and probably long in- 
tervals. It is very remarkable that in most cases of this kind, how- 
ever complete the suppuration may be, the patient scarcely seems to 
suffer during the first seven or eight days. He may perhaps have a 
little nausea, there may be some degree of insomnia, and there may 
also be some failure of muscular strength; and this is all. At the end 
of this time, however, manifest symptoms of the effects of the retained 
poisonous matters on the system arise. These consist in the first in- 
stance in muscular tremors associated with distinct increase of muscular 
debility ; and in the next place in slow, panting respiration, and con- 
traction of the pupils. These phenomena appear never to be absent, 
and they become more and more marked with the progress of the case. 
But soon other symptoms are superadded. The patient complains of 
anorexia and thirst with dryness of the mouth and fauces; he becomes 
drowsy but sleeps only in snatches; and he may present a little occa- 
sional delirium. Death, which is rarely preceded by coma, and still 
more rarely by convulsions, takes place mainly by asthenia at the end 
of two or three days from the first occurrence of toxsetnic symptoms. 
Throughout the patient's illness there is no fever; on the contrary, to- 
wards the close the temperature tends to fall ; the pulse differs little in 
frequency from the normal, and the skin is often moist. The symp- 
toms indeed are widely different from those which are ordinarily attrib- 
uted to uraemia. 

The diagnosis of cases of this kind is often facilitated by the combi- 
nation of a history of some long antecedent attack of renal colic on 
one side, with present symptoms of an acute attack of the same kind 
on the opposite side. The calculus soon, however, becomes impacted 
and then probably all local pain and uneasiness disappear. Further, 
there is no necessary pain or uneasiness in the loin. 

Treatment. — For the treatment of the forms of suppression first re- 
ferred to, simple diuretics, more especially copious bland fluids, the use 



DISEASES OF THE URINARY BLADDER. 



807 



of hot hip or other baths, and the application of counter-irritants to the 
lumbar region comprise everything likely to be of real service. For the 
latter form of suppression we can do little or nothing. We may adopt 
such treatment as is recommended for renal colic, without suppression, 
in the early stage of that affection, in the hope that the stone may suc- 
ceed in reaching the bladder; and we may endeavor, as Dr. W. Roberts 
recommends, by kneading the abdomen to empty the distended ureter 
and coincidently it may be to dislodge the calculus. 



(2.) DISEASES OF THE PELVIC ORGANS. 

The diseases of the genito-urinary organs, situated within the pelvis, 
are of extreme interest and importance ; but they are claimed for so 
many departments of practice that it is difficult to determine to what 
extent they ought to be included in a work on medicine. We propose 
to discuss very briefly, and mainly in reference to diagnosis, those 
among them which are important on account of their liability to be 
confounded with, or to complicate, the diseases already considered, of 
the other abdominal viscera. 



DISEASES OF THE URINARY BLADDER. 

1. Inflammation arises under many different circumstances, which 
need not be enumerated. It is characterized anatomically by conges- 
tion and thickening of the mucous membrane, with the secretion of 
mucus, which may be simply abundant or may acquire the characters 
of pus. Sometimes submucous extravasations of blood occur, some- 
times blood escapes from the surface. Occasionally ulceration takes 
place, occasionally membranous pellicles form, and occasionally the 
mucous membrane itself, or large patches of it, exfoliate and are dis- 
charged. In some rare cases abscesses are developed in the substance 
of the vesical walls, or the inflammation commencing at the mucous 
surface extends in depth until it involves the serous membrane. 

The symptoms of inflammation of the bladder are mainly pain and 
tenderness in the neighborhood of the organ, therefore in the perineum 
and immediately above the pubes, whence it may extend to the penis, 
to the sacrum or loins, and to the contiguous parts of the thighs; irri- 
tability of the bladder, with constant desire to pass w 7 ater ; and the dis- 
charge of urine which, according to circumstances, presents a slight 
cloud of mucus only, or mucus mingled with blood, or more or less 
abundant ropy mucus, or pure pus. Sometimes the urine contains 
shreds of tissue, and in chronic cases frequently becomes alkaline and 
offensive. Cystitis may be acute or chronic, and varies greatly in its 
intensity and danger in different cases. When acute the general febrile 



808 DISEASES OF THE GENITO - URINARY ORGANS. 



symptoms may be very severe. Cystitis often leads to pyelitis ; and, 
further, the latter affection not only resembles cystitis in some of its 
symptoms, but inflammation, commencing in the pelvis of the kidney, 
is apt to travel along the ureter and thus to involve the bladder. 

For the treatment of cystitis we must refer to surgical works and to 
what has been previously said in reference to pyelitis. 

2. Tubercle affects the bladder but rarely, and is then almost invari- 
ably associated with tubercle of the kidneys and ureters, or (which is 
more common) with tubercle of the prostate and vesiculse seminales. 
It is of the miliary variety, and tends, as in the intestines and on other 
mucous surfaces, to produce shallow circular ulcers, which, by coales- 
cence, are apt to cause superficial destruction of some extent. 

The symptoms are in themselves undistinguishable from those which 
indicate some of the forms of cystitis. 

3. Morbid Growths. — The most important of these are villous tumors 
and the several forms of malignant disease. The latter usually com- 
mence in the prostate or some other neighboring part, and are rarely of 
primary origin in the bladder. Tumors are generally attended with 
more or less pain, referable to the bladder, and more or less interference 
with micturition. Moreover, they are apt to be complicated, after 
awhile, with symptoms of cystitis. Villous and malignant tumors are 
frequent sources of profuse haemorrhage. The latter are further char- 
acterized by sooner or later involving contiguous organs, and by induc- 
ing progressive cachexia. 

4. Dilatation. — This condition depends on the accumulation of urine 
or other matters within the cavity of the bladder. It may occur in 
paraplegia and other paralytic conditions from paralysis of the vesical 
walls, and also in hysteria. It is common in the later stages of many 
of the specific fevers, and during the typhoid condition, from the failure 
of the reflex influence on which the evacuation of the bladder depends; 
and it is especially common as a consequence of obstructive disease, 
such as stricture of the urethra, enlarged prostate, or tumors of any 
kind involving or compressing the neck of the bladder. When the di- 
latation is chronic, and secondary to the existence of some impediment, 
the muscular walls become hypertrophied, and sacculi are developed. 
Under any circumstances the mucous surface is apt, after a time, to 
become inflamed ; and the dilatation and inflammation are, both of 
them, liable, sooner or latter, to involve the ureters and the cavities of 
the kidneys. 

Symptoms. — In cases in which retention of urine is dependent on 
paralysis, or is connected with the presence of febrile disturbance or the 
typhoid condition, the bladder may become enormously distended with- 
out causing any apparent suffering to the patient. Even in cases of 
chronic stricture and such like conditions in which, although the dila- 
tation of the bladder may be extreme, it has been slowly attained, the 
organ becomes remarkably tolerant of its burden, and the patient suffers 
comparatively little. In other cases his sufferings are often extreme. 
He complains of more or less general uneasiness, pain and tenderness 
over the hypogastric region, in the penis and in adjoining parts ; but 
the pain is subject to frequent exacerbations, dependent on the violent 



DISEASES OF THE UTERUS AND OVARIES. 



809 



but futile spasmodic efforts of the bladder to void its contents. In 
many cases, if the obstruction be not complete, more or less urine either 
constantly dribbles away or is passed in small quantities during the 
spasmodic efforts. The distended bladder forms a tense, ovoid tumor, 
which rises out of the pelvis from behind the pubes, and may extend 
upwards to the umbilicus or beyond. It occupies the middle part of 
the abdomen, and, unless it be largely sacculated, is symmetrical in 
form and position. The enlarged bladder can rarely fail of recogni- 
tion if due attention be paid to the position and form of the tumor, to 
the perfect dulness on percussion which it presents, and to the charac- 
teristic pain which so often attends it and is evoked by manipulation. 

Treatment. — It need scarcely be said that when the bladder becomes 
distended in the course of fever and paralytic affections, equally as 
when it becomes distended in consequence of surgical diseases, the 
urine should be drawn of; and, if necessary, should be drawn off pe- 
riodically. Further, if the urine be ammoniacal, or there be discharge 
of ropy mucus or of pus, it may be well not only to empty the blad- 
der, but to wash it out either with pure water or with dilute antiseptic 
solutions. 



DISEASES OF THE UTERUS, FALLOPIAN TUBES, AND 

OVARIES. 

Metritis and Oophoritis. 

Causation and Morbid Anatomy. — Inflammation of the parts above 
named may result from various causes, but is most apt to occur during 
the menstrual period and after parturition. Inflammation may affect 
the mucous surface only of the uterus, or this together with the mus- 
cular coat ; and in the latter case is apt to spread to the surrounding 
connective-tissue and to the peritoneum. The Fallopian tubes are 
frequently involved. The inflamed mucous membrane becomes con- 
gested, thickened, and pulpy, and occasionally (especially in the puer- 
peral variety) is thrown off as a slough. The surface may be at first 
dry, but soon secretes a thin fluid, and subsequently pus, with which 
blood may be mingled. When the muscular parietes are involved, they 
become soft, tumid, infiltrated with inflammatory products, and occa- 
sionally studded with spots of extravasation. Sometimes abscesses form. 
Inflammation of the ovary, which is said to be most common on the 
right side, is characterized by swelling, oedema, and congestion of the 
organ, and occasionally goes on to suppuration. The peritoneal surface 
is often involved, and adhesions are then apt to form between the ovary 
and neighboring parts. 

Symptoms. — Metritis is generally a trivial ailment, attended with 
slight febrile symptoms ; but it is sometimes, and more especially in 
puerperal cases, a disease of extreme gravity, rapidly ending fatally 
with symptoms which bear a close resemblance to those of pyaemia or 
of severe erysipelas, with the former of which, indeed, it is apt to be 



810 



DISEASES OF THE GENITO -URINARY ORGANS. 



complicated. The local indications of metritis are weight, pain, and 
tenderness in the situation of the womb. Pain and tenderness are felt 
in the hypogastric region, and occasionally manifest tumor may be 
recognized in that situation. Uneasiness, pain, and soreness are re- 
ferred to the sacrum or lower lumbar region, to the vulva and perineum, 
and to the groins and inner aspects of the thighs. Further, tenesmus 
and painful or difficult micturition are often complained of. When 
the ovary is inflamed, the pain and tenderness are referred to the region 
which the ovary normally occupies, namely, the point of intersection 
of the horizontal line drawn between the anterior superior spines of 
the ilia and the vertical line which divides the median from the lateral 
regions of the abdomen. The organ lies much higher than is generally 
supposed, and is deeply situated. When swollen it may often be dis- 
tinctly felt in this situation. 

Morbid Growths and Cysts. 

Tubercle occasionally affects the uterus and Fallopian tubes ; it com- 
mences at the mucous surface and leads to the gradual destruction of 
the subjacent tissues, and to the abundant accumulation of cheesy 
matter. Much more rarely tubercle is discovered in the ovaries. 
Tubercle of these organs is almost invariably associated with advanced 
tuberculosis of other organs, and more especially of the peritoneum. 

The symptoms, if any special to these organs be complained of, would 
be those of subacute inflammation. 

Myomata are common in the uterus. They probably never occur 
before puberty; and affect virgins, it is said, more frequently than 
married women. They originate in the substance of the uterine walls ; 
if near the inner surface tending to form polypi, if near the outer aspect 
to form pedunculated outgrowths into the cavity of the peritoneum, if 
in the more central parts to remain imbedded. They vary in size from 
mere points up to masses of many pounds weight. They may be single, 
or may be present in large numbers. They are usually slow of growth, 
not unfrequently become stationary, and are liable after a time to un- 
dergo degenerative changes and to shrink. Similar tumors are occa- 
sionally developed in connection with the ovary. 

Symptoms. — In addition to the special symptoms due to their weight, 
to their pressure on neighboring organs, such as the rectum and the 
bladder, to their interference with parturition, and to their influence 
over the uterine functions, myomata frequently form masses which rise 
into the cavity of the abdomen, and may be recognized through the 
parietes as hard, rounded, or nodulated tumors. Such tumors neces- 
sarily vary in size, form, and position, and are generally more or less 
unsymmetrical. Independently of vaginal examination, their situation 
in the neighborhood of the uterus, their shape and density, their slow 
growth, the circumstances under which they have arisen, and the 
absence of involvement of the lymphatic glands and of remote organs, 
and generally of progressive cachexia, will usually enable an accurate 
diagnosis to be made. It must not be forgotten, however, that pedun- 



OVARIAN CYSTS. 



811 



dilated tumors of this kind are apt to become attached to other parts, 
and, especially after pregnancy, to be left in comparatively remote 
situations, and thus to simulate renal or hepatic tumors, or tumors of 
other organs. 

Cystic Tumors. Causation and Morbid Anatomy. — These growths 
are exceedingly common and important. They may become developed 
either in the uterus, Fallopian tubes, or ovaries, or in connection with 
the peritoneal aspect of these organs. 

Dilatation of the cavity of the utents may occur in consequence of the 
accumulation of menstrual fluid, owing either to obstruction at the os 
uteri or to imperforate hymen or vagina. This is an affection of early 
life. At a later period, owing to obliteration of the os uteri, or to its 
obstruction by tumors or other causes, the uterus may become distended 
by the glairy secretion of its mucous surface. Under the latter circum- 
stances the uterus rarely attains a greater size than the fist ; under the 
former it may slowly acquire the bulk of the gravid uterus, or even 
surpass it. The uterus may also become distended with blood. 

The Fallopian tube occasionally undergoes dilatation. This condi- 
tion is secondary to its closure or obstruction, generally at or near its 
junction with the uterus. The affected tube becomes elongated, tor- 
tuous, and sacculated and increasingly dilated towards its fimbriated 
extremity. Here it occasionally measures three or four inches in 
diameter. 

Ovarian Cysts. — By far the most common and important cystic 
tumors are those which arise in the substance of the ovary. These may 
be simple or compound; may vary in size from that of a marble up to 
a bulk far beyond that of the pregnant uterus ; and may form either a 
uniformly rounded or ovoid mass, or an irregular lobulated tumor. 
They may be limited to one ovary, or, as not unfrequently happens, 
may affect both organs in unequal degrees. 

Cystic tumors of the ovary are rare previous to puberty. But from 
twenty or twenty-five upwards they are not unfrequent. They are most 
commonly met with between the ages of thirty and forty. A cystic 
ovarian tumor commences with the development of one or more small 
cysts in the substance of the ovary. These gradually increase in size, 
and as they grow other cysts become developed in relation with them 
either in the substance of the ovary, or, if all manifest ovarian structure 
have disappeared, in the substance of the cyst-walls — a process which 
tends to go on indefinitely as well in the walls of the secondary and all 
other later generations of cysts, as in those of the primary cysts. The 
result is the development of a more or less complicated cystic mass, the 
characters of which will vary according to a variety of circumstances. 

In some cases the secondary cysts largely tend to grow from the 
outer surface of the primary cysts, and hence the tumor soon acquires 
a marked lobulated character ; in some cases they appear mainly in the 
thickness of the party-walls between adjoining cysts, and the tumor 
becomes multilocular, and presents a good deal of resemblance in its 
structure to an accumulation of air-bubbles in a viscid fluid ; in other 
cases the new growths are developed mainly in connection with the 



812 



DISEASES OP THE GENITO -URINARY ORGANS. 



inner surface of the cysts, and project or grow into their interior. The 
last mode of development presents several varieties; in some instances 
papillse or villi or pedunculated cysts spring in groups from the inner 
surface; in some instances, and on the whole more frequently, these 
intracystic growths resemble those from which they spring, themselves 
give origin to others, and thus tend gradually to fill and even to dis- 
tend the cavity into which they grow. 

The proportionate development of the separate cysts presents great 
differences. In some instances one cyst becomes so large relatively to 
the others that the tumor is usually termed unilocular. In others the 
cysts are so numerous and so small that the tumor appears to be nearly 
solid. And between these extremes all varieties may be met with. 
The enlargement of the tumors is not due solely to the formation of 
new cysts, but in great measure to the dilatation of the cavities already 
in existence. This is effected partly by the stretching of their parietes 
by the accumulating contents, and partly by the yielding of their parietes 
at points and the consequent coalescence of neighboring cysts — a pro- 
cess which may be readily observed in all its stages in most ovarian 
tumors. 

The contents of ovarian cysts differ largely. In many cases they are 
colorless ; but not unfrequently they are yellow, brown, or green. 
They may be transparent as water, or opaline, or perfectly opaque. 
They may be limpid, but are more usually glairy or viscid; and not 
unfrequently are thick, and glue or jelly-like. When thick they often 
present a whitish or brownish sediment. Chemically they contain 
modified albumen, and either mucous or colloid matter, and sometimes 
blood in an altered condition. Corpuscles of various kinds, more or 
less degenerated, are generally present; sometimes pus. Cholesterin 
is often observed. 

The walls of ovarian tumors vary greatly in thickness. Sometimes 
they are as thin as tissue-paper and perfectly pellucid. Much more 
frequently they are thick and tough, though varying in thickness in 
different parts. The outer parietes, like the party-walls between cysts, 
have in the progress of their growth a tendency to become attenuated 
and to give way at points. In thin-walled tumors free communications 
are occasionally thus established between the cavities of the cysts and 
the abdominal cavity, which consequently becomes distended with the 
profuse secretion of the ovarian cysts. And even in the thick-walled 
cysts such communication, attended with the escape of their contents, 
is not unfrequent. The walls of ovarian tumors consist mainly of 
connective tissue, in which are not unfrequently found microscopic 
cysts, together with patches or masses of cell growth having some re- 
semblance to sarcomatous or adenomatous tissue. 

Among the various consequences of ovarian cystic tumors may be 
enumerated the occurrence of inflammation or suppuration ; rupture 
of the cysts with the discharge of their contents into the peritoneal 
cavity; the communication of suppurating cysts with the rectum, 
bladder, or other neighboring hollow viscera ; the occurrence of peri- 
tonitis or of ascites ; and pressure on the bladder, rectum, or ureters, 
or on the veins of the lower extremities, with the usual consequences 
of such pressure. 



OVARIAN CYSTS. 



813 



Symptoms and Progress. — The uterus dilated by fluid contents takes 
the ordinary form, and occupies the usual situation, of the gravid 
uterus; and the nature of the case can always be pretty readily ascer- 
tained. For the diagnosis of these cases, however, and of those of 
dropsy of the Fallopian tubes, we must refer to works upon the special 
diseases of women. 

Ovarian cystic tumors are, in the early stages of their growth, either 
unattended with symptoms, or they produce discomfort by sinking into 
the pelvis and interfering by pressure with the functions of one or other 
of the neighboring pelvic organs. At this period they are probably 
detectable through the abdominal parietes, or by vaginal examination. 
With the progress of their growth they rise into the abdominal cavity, 
and ultimately in some cases produce enormous distension, displacing 
the abdominal viscera, and even by direct or indirect pressure on the 
diaphragm interfering with the respiratory functions. An ovarian 
tumor of moderate size can generally be recognized as ovarian by the 
fact of its obvious connection with one or other of the iliac regions, 
whence probably it extends into the adjoining parts of the abdomen ; 
by its irregularity of form and the various degrees of resistance of its 
several lobules, with the probably distinct fluctuation of some; by its 
dulness on percussion; by its displacement of the intestines, and its 
mobility ; and by the absence of pain and tenderness, of cachexia, and 
of secondary growths. When the ovarian tumor has attained a large 
size, all evidence of its commencement at one side of the abdomen has 
probably disappeared. But there is usually even then distinct evidence 
of its development from the lower part of the abdomen in the fact that 
the intestines are displaced upwards and laterally; so that, in addition 
to tumor, there is complete dulness on percussion from the pubes up- 
wards and outwards. [When examining the abdomen especially, with 
the view of ascertaining the organ from which a tumor has taken its 
origin, the physician should not fail to note the exact position of the 
navel, which in health occupies a position just midway between the 
end of the ensiform cartilage and the pubis. In cases of ovarian or 
uterine tumors, the distance from the pubis to the navel will exceed 
that from the navel to the end of the ensiform cartilage, and the reverse 
of this will be true, if the starting-point of the morbid growth is in the 
upper part of the abdominal cavity. Attention to this rule will often 
prevent the occurrence of errors of diagnosis.] The intestinal resonance 
can generally be distinguished in the flanks, and that due to the stomach, 
transverse colon, and perhaps some of the small intestines above. The 
tumor in this case also is probably irregular both as to form and resist- 
ance ; but it frequently happens that one or two cysts preponderate 
largely over the others, and that distinct fluctuation may be felt in them. 
In some cases the bulk of the tumor consists of a single cyst, and the 
tumor may then not only fluctuate distinctly but present a fairly uniform 
rounded shape. Pain, tenderness, and fever are not necessary accom- 
paniments of ovarian tumors; but these phenomena and others may 
arise during the progress of the case. They depend on the superven- 
tion of one or more of those complications which have been previously 
enumerated, namely, inflammation in the cysts or in the peritoneum 



814 DISEASES OF THE GENIT0 - URINARY ORGANS. 



which surrounds them, the development of ascites, or pressure on the 
various pelvic organs. When the tumor becomes very large, the 
patient's gait resembles that of a pregnant woman ; the legs become 
congested and anasarcous ; loss of appetite and perhaps vomiting super- 
vene ; and the breath becomes short. Ultimately progressive emacia- 
tion and asthenia come on. 

Ovarian tumors are generally easy of diagnosis. They are some- 
times apt to be confounded with uterine, hydatid, or other tumors 
springing from the pelvis, and indeed cannot always be distinguished 
from them. When of large size and mainly monocystic they may be 
mistaken for ascitic accumulations. But the anterior position of the 
ovarian tumor ; the existence of resonance above and in the flanks and 
of dulness over the whole of the tumor; the tendency for the abdomen 
to be thick rather than wide and to present some degree of irregularity 
of form; and the total absence of any change in the level of the line 
separating the dull from the resonant regions when the patient shifts 
her position, are usually sufficient to enable an accurate diagnosis to be 
made. It must not be forgotten, however, that ascites is apt to come 
on in the course of ovarian dropsy, and that the two conditions are not 
unfrequently associated. 

Treatment. — The treatment of ovarian cystic tumors alone calls for 
remark here. And even in reference to this subject we have little to 
say. We believe that they are altogether unamenable to specific medi- 
cal treatment. Of course if inflammation arise, the treatment usually 
adopted for peritonitis may be had recourse to ; if the patient be weak 
and emaciated tonics and nutritious diet may be prescribed ; if she be 
suffering materially from the bulk of the tumor and its pressure on 
the stomach, diaphragm, or other organs, it may be tapped. But the 
only .efficacious treatment is by the knife. The success of ovariotomy, 
or of removal of the ovarian tumor by operation, has been so great of 
recent years, especially in the skilful hands of Mr. Spencer Wells, that 
all other forms of treatment have fallen into desuetude, excepting for 
those cases which from various circumstances are unsuitable for the 
radical cure. 

Malignant disease is liable to affect all the organs under considera- 
tion. The uterus is a frequent seat of its primary development; but 
this organ may also be affected secondarily. As a primary disease it 
usually commences between the ages of thirty-five and fifty ; and most 
commonly takes its origin in the cervix or os. Carcinoma is probably 
the most frequent form of the disease, but epithelioma and sarcoma are 
neither of them rare. The ovaries, also, are not very unfrequently the 
seat of cancerous or sarcomatous growths. These may be primary in 
them or secondary to growths elsewhere. They are generally associ- 
ated with the presence of malignant disease in either the uterus, peri- 
toneum, or other abdominal organs. Ovarian malignant disease results 
for the most part in the development of lobulated tumors, which in 
their general outlines are not unlike ovarian cystic tumors; and, in- 
deed, it is common for malignant disease of the ovaries to be associated 
with the development of more or less numerous cysts. 



DISEASES OF THE PELVIC TISSUES. 



815 



The symptoms of malignant disease of the uterus need not detain us. 
And with respect to those of malignant disease of the ovaries it may 
be observed that the tumors would probably in themselves be undis- 
tinguishable from ordinary ovarian tumors, and that their recognition 
as being dependent on malignant disease must rest upon the progress 
of the case, the development of tumors elsewhere, the early appearance 
of cachexia, and the rapid downward tendency of the case. 



DISEASES OF THE PELVIC PERITONEUM AND 
CONNECTIVE TISSUE. 

We cannot conclude this section without directing attention to the 
remarkable tendency there is in the case of the pelvis, as there is also 
in that of the upper part of the chest, for diseases originating in one 
organ to implicate other organs in the vicinity, and for affections, 
therefore, originally distinct, to involve almost identical ultimate 
results. 

Inflammation commencing in the ovary, uterus, or vagina, in the 
rectum, caecum, 'or bladder, in the serous membrane covering these 
organs, or in the connective tissue which invests them, or in connec- 
tion with the bones or joints of the pelvis, are all apt to involve pelvic 
peritonitis with adhesions, infiltration, and induration of the connective 
tissue of the pelvis, and the formation of abscesses which may burrow 
in various directions, and may open either into the bladder, vagina, or 
rectum, or superficially in the perineum, above the pubes, in the groin, 
or in the buttock. Further, as has been before pointed out, abscesses 
may gravitate from any of the parts situated in the abdomen or chest 
along the retroperitoneal tissue, and thus induce the same consequences 
in the pelvis as though they had originated there. 

Similar remarks may be made in reference to the consequences of 
tubercular disease of the uterus and Fallopian tubes, or the prostate 
and vesiculse seminales, and the bladder, the clinical phenomena of 
which are mainly those of subacute inflammation of the same organs. 

Malignant disease of whatever kind soon spreads by continuity from 
the part in which it originates, and implicates all organs in its vicinity. 
If it commence in the uterus or vagina it speedily infiltrates the sur- 
rounding connective tissue, and then presently involves, on the one 
hand, the bladder, on the other the rectum, leading to free communi- 
cations between these several viscera. Similarly malignant disease, 
commencing in the rectum or anus, in the bladder, or parts at the neck 
of the bladder, or in the connective tissue investing these parts, or grow- 
ing from the inner aspect of the pelvic bones, tends to the ultimate pro- 
duction of exactly similar results — to the formation in fact of a common 
I excavation into which the several pelvic organs tend to discharge their 
j contents. 

In the above cases, but more particularly in that of malignant dis- 
ease, other consequences are liable to ensue, more especially, perhaps, 



816 DISEASES OF THE ORGANS OF LOCOMOTION. 



on the one hand, implication of the peritoneum, on the other, the lay- 
ing open of vessels with the occurrence of more or less abundant haem- 
orrhage, and the involvement of nerves, especially those of the sacral 
plexus, with the production of local pain and tenderness and of pain 
taking the course of the sciatic nerve and mistakable for sciatica, and 
apt to be followed by wasting of the muscles and by cutaneous erup- 
tions. Further, impediment to the passage of urine along the ureters, 
with consequent hydronephrosis, retention of urine, impediment to the 
discharge of faeces, tenesmus, irritability of the bladder, and oedema of 
the lower extremities or of the organs of generation, are all liable to 
occur in different cases or at different periods in their progress. 



VII.— DISEASES OF THE ORGANS OF LOCOMOTION. 

EHEUMATISM. {Rheumatic Fever.) 

Definition. — The term rheumatism is often somewhat vaguely applied 
to all inflammatory or painful affections of the fibrous and muscular 
tissues which are not clearly referable to injury, gout, pyaemia, or any 
other well-recognized specific disease. With more precision it is used 
of inflammatory affections of the joints and other fibrous tissues which, 
depending apparently on some general or constitutional morbid state, 
have a tendency to migrate, or to spread, as it were, by a kind of me- 
tastasis. 

Causation. — The essential causes of rheumatism appear to be the 
same as those of pneumonia and many other varieties of idiopathic in- 
flammation, namely, exposure to cold and wet, sudden chills, and long- 
continued exposure to any cooling influence which exercise or clothing 
fails to counteract. Getting wet through, and even having the feet 
damp and cold for any length of time, are common examples of the 
methods by which these agencies act. It must be allowed, however, 
that there are many predisposing causes which exert an important 
influence over the production of rheumatism. Of these we will briefly 
consider some of the most important. If we may accept the results of 
statistical inquiries, it seems clearly proved that the children of rheu- 
matic parents are, on the whole, more liable to suffer than those who 
come of a non-rheumatic stock. Age certainly has some influence, for 
young infants scarcely, if ever, are attacked with rheumatism, and the ! 
old, when they suffer, suffer mainly from its chronic forms or from its 
sequelae. It is probably most common as an acute disease between the 
ages of ten and thirty. Sex has little influence, for although males on 
the whole are more commonly affected than females, the difference is 
probably entirely referable to the influence of their respective avoca- 
tions. The most important, however, of the predisposing causes are : 
first, the fact of having previously had an attack of rheumatism ; and 



RHEUMATISM. 



817 



second, the condition of the patient's health at the time of exposure. It 
is well known, for example, that those who are suffering from scarlet 
fever, those who have gonorrhoea, and women during the period imme- 
diately following childbirth, are peculiarly liable to be attacked with 
rheumatism, which then often becomes modified in its character. Fur- 
ther, inasmuch as rheumatism depends essentially on vicissitudes of 
temperature and other allied conditions, it is of specially common 
occurrence in cold, damp, and more particularly variable climates, and 
during those seasons of the year in which these conditions prevail. 

Morbid Anatomy. — With one or two remarkable exceptions, to be 
presently adverted to, the morbid anatomy of rheumatism calls for 
little comment. The affected joints present more or less hyperemia of 
the synovial fringes and of the parietal layer of the synovial membrane, 
with more or less abundant effusion of synovial fluid into their cavities 
and exudation of serum into the soft tissues around. The former fluid 
may either still present the ordinary characters of synovia, or be turbid, 
milky, or even flocculent. On microscopic examination, the epithelial 
cells of the synovial surface will be found to have become swollen and 
plump, more or less fatty, and in some cases converted into granule 
cells, and similar organisms, together with cells of pus or mucus, will 
be found suspended in the synovial fluid. Changes also go on (accord- 
ing to Cornil and Ranvier) in the articular cartilages. These depend 
mainly on nutritive irritation of the cartilage cells, which swell up, 
assume a globular form, and, according to the usual routine (commenc- 
ing with division of the nuclei), become filled with secondary cells, 
which speedily acquire special secondary capsules. This condition 
does not involve the whole cartilage, but occurs in scattered spots 
which, when they implicate the surface, reveal themselves to the naked 
eye by their prominence and comparative softness. Striation of the 
hyaline matter of the cartilage frequently attends this process, and as 
this is mainly vertical in its direction, the cartilage may assume sooner 
or later a somewhat velvety condition. Rheumatic inflammation rarely 
results either in suppuration or in permanent disorganization of the 
parts affected ; sometimes, however, a joint becomes filled with pus, 
sometimes ulceration of the cartilage takes place, and sometimes the 
tissues external to the cavity become infiltrated with inflammatory 
lymph, matted together, and indurated. The effects of rheumatic in- 
flammation, discoverable post mortem, in most other fibrous tissues 
liable to be affected, are yet more trivial than those which have been 
described, and need no special consideration. 

The lesions of exceptional importance to which reference has been 
made, are rheumatic affections of the heart and pericardium, and simi- 
lar affections more rarely involving the lungs and pleurae. These are 
more particularly pericarditis, endocarditis, pleurisy, and pneumonia, 
which are all fully discussed elsewhere under their respective names. In 
acute rheumatism the blood always contains a large excess of fibrin, 
and it is common after death to find large fibrinous coagula in the 
cavities of the heart and large vessels. 

Symptoms and Progress. — The symptoms of rheumatism are liable 
to very great variety, and especially they are liable to vary according 

52 



818 DISEASES OF THE ORGANS OF LOCOMOTION. 



as the rheumatism confines itself to certain organs or tissues, or becomes 
a more general disorder. The differences, indeed, between these two 
forms of the disease, are so great, that many regard them as entirely 
distinct affections. 

The first form is generally traceable to the direct exposure to cold or 
wet of the part which becomes affected; it is often chronic in its course 
and very intractable, yet by no means necessarily attended with indica- 
tions of constitutional disorder. Sometimes it affects the fibrous struc- 
tures of the soles of the feet, sometimes the muscles of the lumbar region 
(lumbago), sometimes the great sciatic nerve (sciatica), sometimes the 
intercostal muscles, sometimes the muscles of the neck or shoulder, and 
especially, perhaps, the sterno-mastoid (stiff neck, torticollis), in all of 
which cases the local symptoms generally suffice for the identification 
both of the part affected and of the nature of the disorder. 

The more general and acute form of rheumatism, or rheumatic fever, 
as it is often called, sometimes comes on almost suddenly with elevation 
of temperature, alternate heats and chills, possibly rigors, and other 
usual indications of high fever, upon which, in the course of a few 
hours, or perhaps a day or two, the characteristic local phenomena 
supervene. Sometimes, on the other hand, the acute symptoms of the 
general disorder break out in the course of slight rheumatic pains which 
have been for some time flying about the limbs, or have been limited 
to some muscle, or fibrous expansion, or joint; or in the course of one 
of those varieties of localized rheumatism which have already been 
enumerated. But however the acute attack comes on, its symptoms 
(apart from differences due to variations in severity and to the presence 
of complications) present a great and striking simplicity. The parts 
which usually and chiefly suffer are the larger joints, especially the 
wrists, elbows, ankles, and knees; but no joint enjoys immunity; and 
thus we find not only the hip and shoulder joints, and those of the 
spinal column, but those also of the clavicle, and those even of the car- 
pus and tarsus, fingers and toes, all liable to be affected in the course 
of an attack. And, further, the muscles of the limbs and of other parts 
of the body by no means unfrequently suffer. The affected joints be- 
come very painful and exquisitely tender, so that the patient dares not 
move them and cannot bear that they be moved for him or touched, or 
even that his bed be shaken. They usually become more or less ob- 
viously swollen, partly from effusion into the synovial cavity, partly 
from inflammatory infiltration of the surrounding tissues. This swell- 
ing is always most manifest in connection with those joints which are 
least thickly covered, especially, therefore, those of the hands and feet, 
and the wrists, elbows, ankles, and knees. It is mainly in these same 
joints, and along the course of the sheaths of the tendons in relation 
with them that superficial, inflammatory congestion, which is often ab- 
sent, is seen. Rheumatic inflammation is generally characterized not 
only by its tendency to attack joints successively, but by its relatively 
short duration in any one joint. Thus, for the most part, each joint 
which is attacked becomes painful, swollen, and perhaps obviously con- 
gested, and recovers its normal condition, all in the course of a few 
days or even of a few hours ; and it may be added that as a rule neither 



RHEUMATISM. 



819 



pitting nor desquamation ensues. And thus, again, we often find that 
one or two joints only are acutely affected at a time; or that if the pa- 
tient complains of general implication of the joints, some present the 
earliest indications of inflammation, others have attained their highest 
point, while the great majority are in various stages of convalescence. 
It must not be forgotten that there is nothing protective in an attack 
of inflammation of a joint against subsequent attacks in the same joint; 
and that hence the implication of these organs may be repeated indefi- 
nitely in the course of the same attack of rheumatism. 

The general symptoms which accompany the local inflammations are 
in some respects almost as characteristic as the joint affection itself. 
The temperature is sometimes elevated only a degree or two, rarely 
rises above 105°, and generally falls short of this maximum by one or 
two degrees. It is liable to diurnal variations, which, although there 
is commonly a morning remission and an evening exacerbation, are on 
the whole irregular and untypical. Rigors are sometimes present. 
The skin almost invariably yields excessively profuse perspirations, 
which (although not actually more acid than healthy perspirations) are 
attended with a peculiar and almost pathognomonic sour smell. These, 
by their profuseness and long continuance, generally induce a more or 
less abundant eruption of sudamina, which are often seated on congested 
bases, and then apt to be mistaken for eczema. The pulse is quickened, 
but not generally in adults to beyond 100 or 110; it is regular, and as 
a rule more or less full and bounding. The respirations are somewhat 
accelerated ; the tongue is for the most part thickly coated with a moist 
creamy fur, and occasionally becomes dry, brown, and fissured. There 
are failure of appetite and excessive thirst. The bowels are usually 
constipated. The urine is scanty, of high specific gravity, high-colored, 
acid, contains abundant urates, which, with crystals of uric acid, com- 
monly deposit on cooling, and presents an excess of urea and extrac- 
tives, with a deficiency of chlorides. The patient is restless, sleepless, 
often pallid, wears an aspect of weariness, anxiety, or pain, but rarely 
presents delirium or other forms of mental disturbance. 

There is no definite limit to the duration of acute rheumatism. 
Sometimes the patient recovers completely in the course of a day or two 
or of a week ; more commonly the disease persists for several weeks; 
and not unfrequently it becomes chronic, or is continued by successive 
relapses for a much longer period than that. It is generally observed 
that those cases in which the small joints are specially affected are of 
longer duration than those in which the larger joints mainly suffer. 
And, further, it not unfrequently happens that the febrile symptoms 
subside while certain of the joints pass into a chronic condition of dis- 
ease. Sometimes, owing to relaxation of the ligaments, certain joints 
remain more or less weak for an almost indefinite time; sometimes they 
continue stiff and swollen and tender ; sometimes dislocation takes place; 
sometimes the opposed surfaces become adherent, or the soft tissues 
around matted together with chronic inflammatory infiltration, and the 
joints consequently wholly or in part anchylosed or useless. Very 
rarely an inflamed joint suppurates. 

The complications of rheumatism are both numerous and important. 



820 DISEASES OF THE ORGANS OF LOCOMOTION. 



It may, however, be a question whether some of the so-called compli- 
cations should not rather be regarded as integral parts of the disease 
equally with the inflammation of the joints. Rheumatism is charac- 
terized essentially by the occurrence of inflammation of the fibrous 
structures ; for the most part (as has been pointed out) it is those of the 
joints which suffer, but those connected with muscles, nerves, and 
fascia? are also liable to be involved. But of all, excepting those of 
the joints, the fibrous structures of the heart are most frequently im- 
plicated ; and, indeed, the heart in this respect might be regarded as 
one of the joints, for it is at least equally as liable to suffer as any one 
of them. In a very large proportion of cases of acute rheumatism, 
especially among young persons, the heart becomes involved in the 
course of the disease ; occasionally the heart affection precedes that of 
the joints, and it may even be the only local rheumatic manifestation. 
The exact numerical relation between heart disease and rheumatism is 
very difficult to determine, partly because slight attacks of pericardial 
inflammation and the scanty formation of warty masses on the auric- 
ular aspect of the mitral valve may very readily escape detection 
during life, partly because, when once an attack of rheumatism has 
occurred with distinct cardiac complication, it is often impossible to 
be certain whether or not in subsequent attacks further cardiac mis- 
chief has accrued. Endocardial implication is more common than 
pericardial. The symptoms and consequences of the various forms of 
cardiac inflammation are all fully discussed elsewhere; we may, how- 
ever, point out here that the symptoms are often so slightly pronounced 
that the supervention of the cardiac complication may either pass 
unnoticed or be discovered only on casual physical examination, while, 
on the other hand, they are sometimes so grave and dangerous that 
they entirely overshadow those of the general rheumatic attack. It 
need scarcely be said that, in every case of rheumatism, no matter how 
slight it is, the condition of the heart should be carefully watched. 
Pleurisy, pneumonia, and bronchitis, again, are not uncommon com- 
plications of acute rheumatism. ; of these, pleurisy is probably the most 
characteristic. It is often doubtful, however, whether this is due, as 
the endocardial disease is, to the direct operation of the rheumatic 
influence or to simple extension from the previously inflamed peri- 
cardium. Peritonitis is said occasionally to supervene; and jaundice 
(whether from catarrhal inflammation of the ducts or not, may be 
doubtful) is certainly not unfrequent. Inflammation of the iris and 
sclerotic is also not uncommon. Skin eruptions are very apt to occur 
in the course of rheumatism. Reference has already been made to the 
frequent presence of sudamina ; other eruptions are mainly varieties of 
erythema or roseola, and especially of those varieties included by Hebra 
under the generic term of erythema multiforme. They are (to give 
them their specific names) erythema papulatum, erythema circinatum, 
erythema marginatum, and, besides these, erythema nodosum, and, 
according to Trousseau, erysipelas. 

It has already been pointed out that uncomplicated rheumatism, 
however severe it may be, is rarely attended with cerebral disturb- 
ance ; nevertheless it occasionally happens that symptoms referable to 



RHEUMATISM. 



821 



the central nervous organs break out with more or less of the sudden- 
ness that characterizes the onset of cardiac mischief, or that of each 
attack of joint inflammation. The occasional severity and fatal charac- 
ter of these nervous complications has not unnaturally led to the belief 
that the membranes of the brain or cord have become implicated in the 
same way as other fibrous structures, and it is not improbable that in 
some cases this actually takes place. It must be acknowledged, how- 
ever, that post-mortem examination rarely gives evidence of such im- 
plication. In some cases (especially if there be recent heart disease or 
pulmonary complication) the patient may have that kind of delirium 
which so often attends pneumonia and various specific febrile diseases 
— a delirium, mostly occurring between sleeping and waking, and 
from which he can be easily roused. In some cases the patient has, 
more or less gradually developed, some form of mental alienation; 
while quiet in manner, he becomes suspicious and sly, taciturn and 
morose, has hallucinations, hears voices, sees visions, believes that he 
shall be poisoned or murdered, and that the police are on his track, 
and may at any moment become violently maniacal. In some cases 
he becomes hemiplegic, paraplegic, or choreic, or even suffers from 
tetanic spasms, inclusive of lockjaw and risus sardonicus. From all 
such conditions he not uncommonly recovers completely, but sometimes 
they are the precursors of coma terminating in death. Fatal coma is 
ushered in sometimes with lowness of spirits, sometimes with insanity, 
sometimes with delirium or typhomania, sometimes with giddiness or 
headache, or singing in the ears, or affection of the sight, or with 
various forms of paralysis, or with convulsions. Sometimes it comes 
on suddenly with an apoplectic seizure, and death may ensue in 
twenty-four or twelve hours, or even in four or five hours from the 
first appearance of the nervous symptoms. It has been observed that 
in some of these cases there is during the attack either an excessive 
flow of limpid urine, or looseness of bowels, or both. 

Lastly, in relation to the complications of rheumatism, it must be 
pointed out that, although as a rule the temperature in this disease does 
not exceed 105°, it occasionally rises with great rapidity to 107° or 108°, 
or even 110°, 111°, or 112°, and that such excessive rises are almost 
invariably of fatal augury. They always occur in association with 
some of the complications which have been already discussed, such as 
acute cardiac or pulmonary disease, or, above all, with cerebral symp- 
toms. Their connection with the former class of complications is not 
difficult to understand ; their connection with the latter is certainly 
obscure, and none the less so that in some of the cases fatal with cere- 
bral symptoms the temperature presents no unwonted rise. It seems 
probable, however, that both the nervous phenomena and the hyper- 
pyrexia are equally dependent on molecular disintegration connected 
with the presence of some poisonous matter developed in the course of 
the disease and circulating with the blood ; in connection with which 
suggestion it may be pointed out that the skin not only as a rule 
ceases to perspire profusely, but often becomes dry and harsh. Dr. H. 
Weber draws attention to the close resemblance which there is between 
these cases and cases of sunstroke. The relations of rheumatism, 



822 DISEASES OF THE ORGANS OF LOCOMOTION. 



through cardiac disease, with chorea and embolism are fully considered 
elsewhere. 

It will be readily gathered from the foregoing account that, inde- 
pendent of all so-called complications, rheumatism is liable to present 
within certain limits many varieties of character. It may be acute or 
it may assume a chronic form, and may, in fact, continue with relapses 
for months or years ; it may attack chiefly the large joints, or it may 
specially, as it were, select the smaller ones, or it may limit its opera- 
tions almost exclusively, and with extreme severity, to one or two 
joints only ; it may cause inflammation of the synovial membranes 
mainly and effusion into the synovial cavities in one case, inflamma- 
tion of the soft tissues around the joints mainly and infiltration of 
these tissues in another, or inflammation of the fibrous sheaths of 
muscles or of nerves in yet another; when developed in connection 
with gonorrhoea it is peculiarly apt to become intractable and to lead to 
permanent injury of the affected joints ; when it arises after childbirth 
or in the course of some of the specific fevers the inflammation it evokes 
may assume a suppurative character. Yet, however long the duration 
of rheumatism, or however severe, or however various it may be in 
its local manifestations, it is rarely dangerous to life, excepting by 
virtue of one or other of the more serious complications which have 
been discussed ; but these are fatal in a high degree, sometimes imme- 
diately, but more frequently at a later period of life, through the agency 
of the organic lesions of vital organs which they induce. 

Pathology. — It remains to say a word or two in reference to the 
pathology of rheumatism. Is it a local disease, or is it a constitutional 
disease ? Does it depend on the presence of some specific poison cir- 
culating in the blood, on the action of the bloodvessels, on the action 
of the vaso-motor nerves, or on what? These are questions of consid- 
erable difficulty, and impossible to discuss fully in a limited space. It 
seems to us, however, that there is little or nothing in rheumatism, in 
respect of its proximate cause, to distinguish it from pneumonia, bron- 
chitis, nephritis, erysipelas, or other examples of local inflammations 
caused by exposure to cold, or cognate conditions. If these be consti- 
tutional diseases, so is rheumatism ; if they be local diseases rheuma- 
tism is in the same sense also a local disease — a disease, that is to say, 
involving a special tissue which, however, happens to be largely dis- 
tributed throughout the system. [Although much may be said in favor 
of this theory, it may be objected to it that while, in the purely local 
diseases, as for instance bronchitis, the inflammation extends occasionally 
from the larger to the smaller tubes, it does not subside in the former, 
but continues with undiminished intensity. In rheumatism, on the other 
hand, all inflammatory action may disappear from the joint first affected, 
leaving it apparently in a perfectly healthy condition; the general 
character of the disease being shown in the coincident or subsequent 
involvement of other joints.] That the blood becomes abnormal in rheu- 
matism is certain, and especially it is certain that it contains an exces- 
sive quantity of fibrin and of the products of disintegration of tissues; 
but these are the mere consequences of the rheumatic process, and have 
no more to do with the production of rheumatism than the similar 



RHEUMATISM. 



823 



condition of the blood in pneumonia has to do with the production of 
pneumonia. The proximate cause of rheumatism has been largely 
held to be a poisonous substance circulating in the blood, and the copi- 
ous perspirations have been regarded as an effort of nature for the 
elimination of this poison ; it has even been maintained that the poison 
is either lactic acid or some other form of acid. No excess, however, 
of lactic or other acid has been as yet detected in the blood or perspi- 
ration of rheumatic patients, and if there be a rheumatic poison, which 
is certainly possible, its discovery is in the future. 

Treatment. — Innumerable remedies have been vaunted for the cure 
of rheumatism, yet.it remains one of the most unmanageable complaints 
which physicians can be called upon to treat. Some advocate the use 
of iodide or bromide of potassium in frequent medium doses; some 
that of nitrate of potash in daily quantities varying between 1 and 3 
ounces largely diluted as taken as a drink; some that of alkalies, and 
more especially of the bicarbonate of potash in doses of from 20 to 30 
grains given every hour or two; some recommend colchicum, some 
veratria, some guaiacum, some quinine, and some opium, in quantities 
sufficiently large and sufficiently frequently repeated to induce their 
respective specific actions. Dr. Garrod prefers a combination of qui- 
nine and bicarbonate of potash in about 5 and 30 grain doses respec- 
tively. Salicylic acid in hourly doses of from 7 to 15 grains has recently 
been largely employed, especially in Germany, with reputed great suc- 
cess. [It has also been recently used in this country with the effect, it is 
said, of diminishing, the duration of the disease.] Others trust mainly 
to local treatment : simple hot fomentations, hot fomentations with 
which alkalies and laudanum have been mixed, counter-irritation by 
means of spirit or turpentine, mustard plasters or blisters. Blisters 
especially have been recently brought into prominent notice by Dr. 
Herbert Davies. Others, again, trust to " packing," or to vapor, hot- 
air, or hot-water baths. 

As a general rule a rheumatic patient should be kept in a comfort- 
ably arranged bed well covered with bedclothes, and protected if neces- 
sary by mechanical means from their undue pressure ; perspirations 
should be encouraged, and the inflamed joints covered with cotton- 
wool ; pain should be relieved and rest obtained by the administration 
of opiates ; thirst should be appeased and secretions encouraged by 
the administration of abundant diluents, such as lemonade, soda-water, 
milk, beef tea, and broths; and nutrition should be maintained by the 
use of such food (mostly fluid and farinaceous) as the patient can be 
persuaded in reason to take. He should be placed in a warm room, 
well ventilated, yet free from draughts, from which indeed he should 
be protected by curtains. In addition some one of the lines of medic- 
inal treatment above indicated may be pursued, or counter-irritation 
may be practiced. As regards the use of blisters we may state that 
they do, according to our own experience, afford almost immediate and 
marvellous relief to the pain of the inflamed joints in the neighbor- 
hood of which they are placed, and that they may be applied to joint 
after joint in the progress of rheumatism without any ill effect what- 
ever, but that they do not cut short the progress of the inflammation 



824 DISEASES OF THE ORGANS OF LOCOMOTION. 



which they relieve, and have no influence whatever over the general 
progress of the rheumatic attack. [The bromide of ammonium in 
doses of from 15 to 20 grains repeated every three or four hours will 
often be found, in connection with the alkalies, a valuable remedy in 
rheumatism. While it cannot be asserted of it that it cuts the disease 
short or entirely prevents the occurrence of cardiac complications, it 
certainly relieves pain and diminishes restlessness.] It may be added 
that colchicum is said to be specially efficacious when the rheumatism is 
attended with marked dropsy of the synovial cavities ; and that iodide of 
potassium or guaiacum is reckoned to be chiefly beneficial in chronic 
cases. During convalescence from rheumatism, great care should be 
taken to avoid cold and draughts, and the patient should be warmly 
clothed in flannel. He should, moreover, be put on a course of quinine 
and iron or some other tonic, well fed, and if necessary removed for a 
time at least to some more genial neighborhood. 

When rheumatism becomes chronic, or rheumatic - pains are a source 
of trouble from time to time, or the patient suffers from rheumatism 
of certain fasciae, muscles, or nerves, various measures are open to us 
to adopt for his relief. Hot-air baths, vapor baths, hot- water baths, 
Turkish baths frequently repeated are often exceedingly valuable. 
Counter-irritation, especially by means of blisters or stimulating lini- 
ments, hot fomentations, the application of belladonna or aconitin, 
or even the removal of blood by leeches, may be of more or less bene- 
fit. Opiates, especially given by subcutaneous injection, are often of 
marvellous efficacy. For general treatment, we may have recourse to 
the drugs which are supposed to be serviceable in the acute form of 
the disease ; but those which are most likely to be of use now are 
probably iodide of potassium, guaiacum, quinine, iron, and other va- 
rieties of tonics. 

For the treatment of the various complications of rheumatism we 
must refer the reader to the articles in which these affections are spe- 
cially considered. We may, however, observe that when cerebral or 
spinal symptoms manifest themselves it is generally advisable to act 
freely on the bowels, to employ revulsive treatment, and to place our 
trust (as regards internal remedies) in opium and diffusible stimulants. 
If hyperpyrexia come on — if the temperature rise above 105° or 106° 
— then it may be advisable to reduce it by the application of external 
cold. This may be done either by sponging the patient's body with 
tepid or cold water, or by surrounding him with sheets kept moist and 
cool by pouring water over them from time to time, or best of all by 
placing the patient in a bath, the temperature of which may at the 
beginning stand at about 98°, but which is allowed gradually to be- 
come reduced to 60° or 70°. The patient may be subjected to such 
treatment for half an hour or even an hour at a time; but the pro- 
priety of continuing or determining it must be judged of by his condi- 
tion. It should not be continued after he begins to shiver or look 
cold, or after his temperature has been reduced to 100° or 101°. But 
if the temperature rises it may need to be repeated frequently and at 
short intervals. There is no doubt that patients are often temporarily 



RHEUMATOID ARTHRITIS. 



825 



benefited by this treatment in a remarkable degree. It is less certain 
that their ultimate recovery is materially promoted by it. 



RHEUMATOID ARTHRITIS. (Chronic Rheumatic Arthritis.) 

Definition. — This affection, which consists essentially in a chronic 
irritative outgrowth of the cartilages and synovial fringes of the joints, 
associated with progressive destruction of those parts of the cartilages 
which are most subjected to pressure, has been described under va- 
rious names, among which may be mentioned " chronic rheumatism," 
" chronic rheumatic arthritis," " nodular rheumatism," and " arthritis 
deformans." 

Causation. — It occurs far more frequently in women than in men ; 
and in them comes on mostly, it is said, at about the period when 
menstruation ceases. It may, however, commence at any time of life, 
and has been recognized even in young infants. Its cause is obscure ; 
it is certain, however, that many of those who suffer from it have had 
acute rheumatism of the ordinary type at some earlier period of life; 
that in some cases its commencement may be clearly traced to those 
conditions which are productive of acute inflammation ; and that most 
of those who suffer from it are especially sensitive to vicissitudes of 
temperature and changes of season. The subjects of this affection are 
always more or less anaemic, but whether anaemia and debility are to be 
regarded as anything more then predisposing causes in some cases, or 
as consequences in others, is exceedingly doubtful. 

Morbid Anatomy. — In rheumatoid arthritis the morbid processes are 
confined to the articular cartilages and to the synovial fringes. The 
central areae of the articular cartilages, to a variable and gradually in- 
creasing extent, acquire a velvety or villous character, get worn down 
by degrees, and finally disappear, leaving the subjacent bone exposed, 
which then assumes an ivory-like compactness and smoothness. But 
while the central portions are thus disappearing, the margins form 
nodular outgrowths of extreme irregularity, both in size, shape, and 
arrangement. The synovial fringes take part in the hypertrophic pro- 
cess, and form bulbous or pyriform excrescences, varying in size, and 
often collected into clusters of more or less complexity. They are at 
first fibrous, but soon become the seat of cartilaginous formation ; and 
both they and the ecchondroses tend to undergo ossification, and often 
after awhile become converted wholly into bone. These outgrowths in 
some cases blend with the osseous structure of the epiphysis, in some 
cases remain connected with it by fibrous or cartilaginous pedicles, and 
occasionally become detached and free. The gradual progress of the 
disease leads to the lateral expansion of the joint surfaces and to ex- 
treme irregularity with nodular enlargement of the margins of the 
joint ends of the bones, and to more or less dislocation, deformity, and 
immobility. All joints are liable to be thus affected — those of the 
hands and feet, those of the arms and legs, those of the jaws, and 



826 



DISEASES OF THE ORGANS OF LOCOMOTION. 



those also of the spine. The intimate changes which take place in 
the cartilages in this affection are, in the first instance, enlargement 
and proliferation of the cartilage cells. In the central area? of op- 
posed cartilages, where they are subject to constant mutual pressure, 
the enlarging cavities which contain the multiplying cells communi- 
cate with one another in vertical linear series, and open at the surface 
of the cartilage, and thus discharge their cellular contents into the 
synovial cavity ; by this means the hyaline substance of the cartilage 
becomes honeycombed by vertical pits, or split into vertical columns, 
and thus acquires its characteristic velvety appearance. The prolifera- 
tion, however, of the cartilage cells at the periphery (where growth is 
less interfered with) and of the synovial fringes results in the actual 
overgrowth of these parts, and in that further development of them 
which has been described. 

Symjrfoms and Progress. — The symptoms of rheumatoid arthritis are 
mainly those which are due to the gradual advance of deformity, dis- 
location, and loss of mobility in the affected joints, and to a tendency 
to the gradual implication in the disease of most or all of the joints of 
the body. But with these are associated more or less pain and tender- 
ness, rarely acute, in the affected joints, coming on at irregular inter- 
vals and attended with more or less febrile disturbance ; wasting of the 
muscles connected with the diseased joints, with spasmodic cramp-like 
pains in them ; and more or less marked ana?mia. The disease, as has 
been stated, may follow immediately or remotely on an attack of acute 
rheumatism ; but in many cases it is chronic or subacute from the 
beginning. The patient complains, perhaps, of slight pain, tenderness 
and swelling in one or more of the joints, probably those of the knees, 
or wrists, or fingers, and at the same time of slight feverish ness ; but 
in a short time, with rest and confinement to the house, these symptoms 
subside. After a short interval, however, the phenomena recur, and 
probably with greater intensity, and possibly other joints besides those 
first affected now become implicated. Again, perhaps, the symptoms 
subside. These attacks continue, however, to recur for the most part 
at shorter and shorter intervals, to implicate a gradually increasing 
number of joints, and to leave them (in the intervals of subsidence) 
still swollen and tender, and to render them more and more useless. 
At length, after the lapse of some months, or it may be some years, the 
patient becomes thoroughly crippled, most of his joints, or all of them, 
are swollen, distorted, and more or less rigidly fixed ; all his muscles 
are wasted ; and his arthritic and muscular pains, now never wholly 
absent, are liable to frequent exacerbations, especially in connection 
with changes of temperature. 

Rheumatoid arthritis usually commences in the hands, and more 
especially in the metacarpophalangeal joints of the fore, middle, and 
ring fingers; the wrists and knees are also early implicated. The 
upper extremities usually suffer before the lower extremities, and 
although the metatarso-phalangeal joint of the great toe generally be- 
comes affected in the course of the complaint, it is rarely or never the 
primary seat of attack. The articulations of the jaws and of the spine 
are for the most part implicated at a late period only of the disease. 



RHEUMATOID ARTHRITIS. 



827 



The nodulated condition of the joint-ends of the bones is usually most 
distinctly marked in the finger joints, which become irregularly swollen, 
in the ball of the great toe, in the wrists, elbows, and knees; it is in 
these same joints, too, and in the hips, that imperfect dislocations most 
commonly occur. When the joints are rigid and fixed, they usually 
present the position of flexion ; the thighs are flexed on the abdomen, 
the legs on the thighs, and the forearms on the upper arms, with at 
the same time some degree of pronation. The wrists generally con- 
tinue in a straight line with the forearms, or present some degree of 
tilting towards the ulnar side, but the fingers acquire various and 
strange distortions. -The most frequent form of distortion is that in 
which, while the first and third plalanges are flexed, the second or 
intermediate phalanx is extended. The thumb is usually extended. 
Rheumatoid arthritis, though generally a progressive disease, and in- 
capable of cure, occasionally remains limited to one or two joints, and 
occasionally becomes arrested in its progress, or even (so far as the 
structural changes which have taken place permit) undergoes a more 
or less perfect cure. 

Pathology — -The relation between rheumatoid arthritis and acute 
rheumatism is not easy to determine. It is quite certain that acute 
rheumatism very rarely induces the characteristic morbid processes of 
the former disease; and that rheumatoid arthritis is rarely attended 
with the profuse perspirations, the febrile urine, and the visceral com- 
plications which attend acute rheumatism. On the other hand, rheu- 
matoid arthritis is essentially a kind of inflammation of the very struc- 
tures which are mainly implicated in acute rheumatism ; the joints 
become successively and symmetrically involved as in the latter disease; 
and, with reference to the absence of sour perspirations and the like, it 
must not be forgotten that these may be entirely absent in cases of 
chronic, or subacute, or muscular rheumatism ; and as regards visceral 
complications, Trousseau shows that the evidences of peri- and endo- 
carditis are sometimes afforded in these cases, and that even cerebral 
mischief may occasionally supervene. Moreover, as Garrod points 
out, inflammation of the sclerotic and of other fibrous textures now and 
then attends rheumatoid arthritis. On the whole, we are inclined to 
regard it as a chronic inflammatory process, which is not necessarily, 
but is in a large number of cases, a sequela of acute rheumatism. 

Treatment. — For the general treatment of rheumatoid arthritis we 
must refer to what has been already said in reference to the treatment 
of acute rheumatism. For the most part, however, we must trust to 
local measures and to constitutional treatment calculated to improve the 
general health of the patient. Locally, friction, counter-irritation, the 
inunction of the parts with preparations of iodine or mercury, the main- 
tenance of the joints in one position by suitable apparatus, are all more 
or less important. Hot fomentations again are valuable, and especially 
perhaps (as recommended by Trousseau) the burying of the joint in 
sand heated up to 140° or 150°, keeping it there for an hour or two at 
a time, and repeating the operation three times a day. 



m 

828 DISEASES OF THE ORGANS OF LOCOMOTION. 



GOUT. (Podagra.) 

Definition. — Gout is a disease which is characterized by the deposi- i 
tion of urate of soda in a crystalline form in the cartilages and other 
textures of joints, and elsewhere among the fibrous tissues, and by re- 
current attacks of articular inflammation. It is usually attended also 
with constitutional symptoms and grave lesions of important organs. 

. Causation. — Gout is mainly a disease of middle and advanced life, 
and of the male sex, and generally first makes its appearance between 
the ages of thirty and forty-five. It is sometimes, however, met with 
at or about the period of puberty, and has occasionally made its first 
appearance as late as the eightieth or even ninetieth year. In women 
it rarely shows itself until after the cessation of the menstrual flow. 
The influence of hereditary predisposition in the production of disease 
is probably nowhere more clearly evinced than in the history of gout; 
and, indeed, Dr. Garrod's experience leads him to the belief that more 
than half the total number of gouty patients have clearly inherited the 
gouty proclivity from their parents. On the other hand, it is certain 
that gout is largely induced by habits of life, and that even where an 
hereditary taint exists, the influence of habits in accelerating the first 
attack or in postponing it, or even in preventing the occurrence of the 
disease, is still very considerable. As regards habits, it seems to be 
universally admitted that long-continued indulgence in alcoholic bever- 
ages, long-continued overeating, especially of animal food and of rich 
dishes, and prolonged insufficiency of exercise, are (especially in combi- 
nation) powerful agents in the causation of gout. It is, however, gen- 
erally held that all alcoholic beverages are not equally injurious in this 
respect, that the distilled spirits are comparatively innocuous, that the 
light wines, claret, hock, moselle, and the like, are also fairly whole- 
some, but that the strong wines, sherry, and madeira, and above all 
port, and malt liquors, are all virulent gout-producers. But on what, 
it may be asked, do the injurious effects of alcoholic beverages depend? 
If, as seems reasonable to assume, they are due to the alcohol which 
they contain, how can we accept the statement that the distilled spirits 
are almost harmless, while bitter ale and porter are highly poisonous? 
If, on the other hand, the alcoholic constituent be acquitted, must we 
refer them to the comparatively simple matters which give to alcoholic 
beverages their respective flavors, or their colors, or their body ; matters 
which are, most of them, not special to such beverages, are most of 
them certainly not unwholesome, and individually form an insignifi- 
cant percentage of the whole? We must confess our distrust of the 
evidence which, while accusing alcoholic drinks of causing gout, acquits 
the alcohol itself. On similar grounds we venture to submit, not- 
withstanding almost universal testimony to the contrary, that port is 
no more injurious than sherry or madeira, or other wines of equal 
strength. It is probably less in consequence of the port which they 
drink than of the association in their case of overdrinking, overfeed- 
ing, and want of exercise that the higher classes suffer more frequently 
from gout than those who occupy a lower station of life. It must be 



gout. 829 

| added that fatigue, exposure, indigestion, and whatever impairs the 
i health, and injuries inflicted on joints, are all apt to bring on attacks 
I of gout in those who are liable to the disease. The impregnation of 
! the system with lead is also said to induce a susceptibility of gout. 

Morbid Anatomy. — The morbid phenomena of gout are chiefly mani- 
I fested in the joints and the tissues which surround them. The earliest 
' appearances are furnished by the superficial portions of the articular 
! cartilages, which seem dusted, so to speak, with spots and patches of 
| an opaque white color. As the morbid process extends, the cartilages 
I become more and more generally infiltrated, until they look like a mere 
' mortary incrustation of the joint surfaces of the bones. Later still, 
similar mortary patches appear imbedded in the substance of the syno- 
vial membranes, and gradually involve them more or less completely; 
and at the same time, or later, masses (which eventually vary perhaps 
from the size of a pea to that of a filbert) become developed in the sub- 
i stance of the soft tissues surrounding the joints, in the bursse, and in 
the cancellous tissue of the subjacent bones. The changes, however, 
! do not end here. The infiltrated cartilages lose their vitality, become 
; brittle, gradually eroded, and finally removed, exposing the bone be- 
neath, which itself may sooner or later undergo destructive changes. 
The margins of the affected cartilages, on the other hand, not un fre- 
quently become irritated into overgrowth, and form nodular enlarge- 
ments like those of rheumatoid arthritis. The accumulations of mor- 
tary masses in the tissues about the joints, which constitute chalk-stones 
| or tophi, gradually provoke erosion of the swollen and congested tissues 
which cover them, until finally an opening is formed from which they 
escape. The appearances above described are due to the deposition in 
the substance of the cartilages, and elsewhere where such deposits are 
found, of needle-like crystals of urate of soda arranged for the most 
part in dense, opaque, stellate clusters. This deposition appears to 
commence within the cells, and although the needle-like rays extend 
thence into the surrounding intercellular substance, it is still to the 
cells that the crystalline formation is mainly confined. Gouty forma- 
tions, as a rule, first manifest themselves in connection with the meta- 
tarso-phalangeal joint of one or other of the great toes, usually the 
right, occasionally both, and may remain thus limited for a consider- 
able length of time. But gradually other joints (and for the most part 
with more or less symmetry of arrangement) become involved — the 
smaller ones, as a rule, first, the larger ones at a later period. Thus, 
after the metatarso-phalangeal joints of the great toes, the other toe^ 
joints and the joints of the tarsus, fingers, and carpus, the sterno- 
clavicular articulations, the ankles and wrists, the knees and elbows, 
and finally the hips and shoulders, and other joints, become succes- 
sively the seats of disease. The joints connected with the laryngeal 
cartilages also occasionally suffer. Gouty deposits, moreover, are apt 
to become developed along tendons, chiefly in the neighborhood of 
gouty joints ; beneath the periosteum of the tibiae and other bones ; in 
the course of the smaller vessels and nerves ; and in connection with 
the perichondrium of the external ear, the tarsal cartilages, and the 
sclerotic coat of the eye. In the ear they mainly affect the convex 



830 



DISEASES OF THE ORGANS OF LOCOMOTION. 



edge of the helix ; in the tarsal cartilages, those portions which imme- 
diately adjoin the edges of the palpebral orifice. 

The ultimate effects of gout upon the joints are in most cases very 
serious. They become irregularly swollen, partly from inflammatory 
and gouty infiltration of the tissues which surround them, partly from 
the changes which have been going on in their interior. The irregu- 
larity, consequently, is not, as in rheumatoid arthritis, limited to the 
joint-ends of bones, but occupies the intermediate regions at least equally, 
and probably in a still greater degree. The articulations become more 
or less fixed, generally in some inconvenient position, and, it may be, 
more or less dislocated : these results being due in various degrees to 
the changes which have taken place in the soft tissues around, to uratic 
infiltration and loss of suppleness in the synovial membranes and liga- 
ments, and to actual anchylosis, which sometimes follows the complete 
removal of the cartilages. Chalk-stones form more or less abundantlv 
in the tissues external to the joint cavities, adding to the apparent bulk 
of the joints and to their knotty irregularity, and finally become dis- 
charged through ulcerated openings, which, still secreting large quan- 
tities of chalky matter, may remain patent for years. The deformities 
and other ulterior changes here enumerated occur most frequently, 
earliest, and with greatest severity, in the joints of the hand; next in 
order in those of the feet; next in the wrists, elbows, ankles, and knees ; 
and finally in the hips and shoulders. 

It is rare to find in the necropsy of gouty persons that all other or- 
gans save those of which the morbid conditions have just been described 
are in a perfectly healthy condition. It could scarcely be expected, 
indeed, when one looks to the circumstances under which, as a rule, 
gout arises, that the internal viscera should escape those degenerative 
changes which so commonly follow long-continued persistence in bad 
habits, or attend that tendency to premature decay which some of us 
unfortunately inherit. It is not surprising, therefore, that gouty pa- I 
tients are liable to have degenerated arteries, valvular lesions and other 
morbid conditions of the heart, emphysema of the lungs, cirrhotic 
liver, and contracted granular kidneys. The last lesion, indeed, is so I 
common in gout that it is not unfrequently termed the "gouty kidney." ! 
The kidneys of gouty patients, moreover, often present, especially in 
the cones, linear aggregations of a buff-colored material, which is, in 
fact, a deposit of urate of soda, either in stellate crystals in the matrix, 
or in an amorphous form in the tubules; and sometimes concretions 
of the same material adhering to the mammillary processes. These 
formations are not, however, characteristic of gout, and are frequently 
found in persons who have no gouty tendency, and even in newly-born 
children. 

Symptoms and Progress. — It has been distinctly shown by post-mor- 
tem examination that the gouty deposit takes place in the cartilages of 
the joints long before the joints themselves becomes inflamed or give 
any clinical evidence of the nature of the process which is going on in 
them — a fact which is confirmed by the total freedom from inflamma- 
tion and pain which usually attends the formation of those uratic con- 
cretions which are met with in connection with the cartilages of the ear 



GOUT. 



831 



and the periosteum. And hence it may be assumed that at any rate a 
very large proportion of those who ultimately become distinctly gouty 
have been really gouty for a considerable time previously to the first 
considerable outbreak ; and hence also it is easy to understand that in 
many cases the first attack may have been preceded by premonitory 
symptoms, such as occasional pain or tenderness in one or both great 
toes, or in other of the smaller joints, such as those of the fingers, wrists, 
ankles, or clavicles. 

The first so-called "attack of gout " almost invariably comes on 
suddenly with some pain and swelling in the ball of one of the great 
toes, usually that of the right. It comes on, moreover, usually at the 
early part of the year, and almost without exception in the night-time. 
The patient goes to bed probably in his usual health, but wakes about 
two or three o'clock in the morning withTnore or less severe pain in 
the metatarso-phalangeal joint of one of his great toes. The agony is 
sometimes so intense that he dares not move the affected limb; he 
cannot bear the pressure of the bedclothes, or even the slightest jar to 
his bed or the lightest movement in his chamber ; his sufferings, too, 
are often aggravated by cramps and involuntary shootings in the mus- 
cles of the leg ; he becomes restless and hot, shivers, sometimes has re- 
peated rigors, and, after tossing about for some hours, falls into a per- 
spiration ; and then somewhere about the time when he should be think- 
ing of getting up, falls into a gentle sleep, from which, in the course 
of a few hours, he awakes, refreshed and comparatively easy, but with 
the great toe joint swollen, tense, and vividly red, and with the super- 
ficial veins of the foot, and probably some of those extending up the 
leg, unusually distinct and full. He most likely continues compara- 
tively well throughout the day, and may even be able to limp about on 
his maimed limb ; but with the advance of evening, or it may be in the 
early hours of the ensuing morning, he has a more or less severe re- 
currence of the local pain and of the febrile symptoms which marked 
the first attack, to be again followed after the lapse of a few hours by 
a second intermission. These nocturnal exacerbations, succeeded by 
matutinal remissions (lasting usually till evening), come on with com- 
parative intensity for two or three successive nights, and then gradually 
diminish in severity, until at the end probably of a week or ten days, 
it may be a little more or a little less, all febrile symptoms and all acute 
suffering have passed away. The affected joint, however, probably re- 
mains swollen, weak, and more or less tender for some week or two 
longer. During the attack, the ball of the toe becomes, as has been 
stated, tense, swollen, vividly red, generally more or less shiny, and 
exquisitely painful and tender. Most of these conditions usually at- 
tain their maximum by about the second day, after which the pain and 
tenderness gradually subside, and the redness becomes of a dusky hue ; 
but the swelling still for a time increases, and probably extends far be- 
yond the limits of the seat of inflammation. Much of the swelling, in- 
deed, is now due to simple oedema, and the parts pit on pressure. 
But soon the swelling also begins to disappear; and desquamation fol- 
lows. The febrile symptoms, from which the patient suffers in a greater 
or less degree during his attack, are, as has been indicated, of a remit- 



832 DISEASES OF THE ORGANS OF LOCOMOTION. 



tent type, and are attended not only with shiverings or rigors, and per- 
spirations, but frequently also with a furred tongue, loss of appetite, 
thirst, and constipation, and a febrile condition of urine. 

It occasionally happens that even in the first attack of gout both 
great toes are simultaneously or sequentially implicated, or that not 
only the toes, but the ankles, knees, and other joints successively suffer, 
in which case especially the affection may present a close resemblance 
to acute rheumatism ; or, again, that the first attack, instead of sub- 
siding speedily, as it usually does, continues by a series of successive 
outbreaks of no great intensity in the same joint for weeks or months. 
It sometimes also happens that the first attack of gout is in the ankle 
or knee or some other joint than that of the toe, a circumstance which 
is obviously due in some cases to the influence of some accident to the 
joint or of some other lesion. 

The first attack of gout may also be the last. But far more com- 
monly a second attack supervenes sooner or later, occasionally not for 
eight or ten years, sometimes after an interval of a few months only, 
more frequently at the end of a year or two. To the second attack 
other attacks succeed, at first separated from one another by intervals 
of probably about twelve or six months, but gradually approaching one 
another until at length the patient, though still liable to exacerbations, 
is perchance never actually free from suffering. Further, each succes- 
sive attack, as a rule, implicates a larger and larger number of joints: 
those joints, moreover, which have been most frequently affected gen- 
erally suffering most severely. Gradually these grow lumpy and de- 
formed and rigid ; the patient becomes more and more crippled ; chalk- 
stones form and discharge themselves through ulcerated openings; the 
general health deteriorates; and death, usually dependent on some 
visceral complication, finally ends the scene. The pain which attends 
the later attacks of gout, although more continuous, is rarely so acute 
as that of the earlier outbreaks ; and, further, the degree of disorgani- 
zation of joints and the amount of urate of soda deposited in or about 
them are by no means necessarily related to the frequency or severity 
of the attacks of inflammation from which the joints have suffered. 

The condition of the urine in gout, which has been carefully inves- 
tigated by Dr. Garrod, has already been referred to. During the febrile 
paroxysms it is scanty and high-colored, of high specific gravity, and 
generally deposits on cooling an abundant sediment. It contains re- 
latively to its bulk an excess of urates, but the total amount of these 
passed in the twenty-four hours is absolutely less than in health. The 
urea is also probably somewhat diminished. In the chronic form of the 
disease the urine is pale, abundant, of low specific gravity, generally 
yielding no deposit, and presenting (as in the febrile stage) a dimin- 
ished daily quantity of urates and of urea. It often contains a small 
amount of albumen, with hyaline or granular casts. The condition of 
the blood has also been investigated by Dr. Garrod, who finds that 
during the inflammatory attacks of acute gout it contains urate of soda 
in relatively large abundance, while none can be detected in it previous 
to the occurrence of inflammation or after its subsidence; but that, 
when the gout assumes a chronic or inveterate character, urate of soda 



GOUT. 



833 



is present in the blood both daring the exacerbations and in the inter- 
vals. He has also found in the blood oxalic acid, which he refers to the 
decomposition of the retained uric acid and urea, the presence of which 
has probably always been dependent on associated renal disease. 

In the foregoing account many of those phenomena which by some 
authors are regarded as among the most important in the history of 
gout have been passed over in almost complete silence. We refer, on 
the one hand, to the premonitory symptoms referable to functional 
lesions of various organs, and, on the other, to the various sequelae or 
complications which from time to time present themselves. Gouty 
persons are usually more or less dyspeptic ; and it is not unnatural, 
therefore, that dyspeptic symptoms should in a large number of cases 
precede the gouty paroxysms, and persist more or less during the in- 
tervals between successive attacks. Among the premonitory symp- 
toms, therefore, may be enumerated epigastric discomfort, pain, flatu- 
lence and eructation, with more or less constipation or disturbance of 
the bowels, palpitation, dyspnoea, headache, drowsiness, restlessness, 
moroseness, instability, and violence of temper. Such symptoms often 
attend the gouty outbreak, but, on the other hand, they are said to be 
frequently removed by it. The sequelae and complications of gout are 
numerous, and may be considered seriatim in connection with the 
organs which are their seat. In connection with the nervous system 
occur vertigo, headache, convulsions, mania, apoplexy, anaesthesia, 
paralysis, hyperesthesia, lumbago, sciatica, and various other neuralgic 
pains ; in connection with the vascular system, palpitations, syncope, 
angina pectoris, and various forms of structural cardiac disease ; in 
connection with the lungs, asthma, bronchitis, and emphysema; in 
connection with the gastro-intestinal tract, dyspepsia, gastralgia, irregu- 
becomes indurated or cirrhotic, and jaundice, ascites, or melaena may 
larity of bowels, and haemorrhoids. Further, the liver not unfrequently 
ensue ; the kidneys in a large number of cases get contracted and 
granular and incompetent, and the patient tends to suffer from anasarca 
and other results of kidney disease ; the bladder becomes irritable or 
inflamed ; concretions form in the urinary passages, or mucous or puru- 
lent discharges take place from them ; and, lastly, skin affections often 
become developed, especially perhaps chronic eczema and psoriasis. 
But none of the symptoms or lesions here enumerated are peculiar to 
gout; and their frequent coexistence with it is doubtless in large 
measure dependent on the fact that sufferers from gout are on the 
whole persons whose internal organs are in a greater or less degree in 
an abnormal condition, and whose bodily functions tend, therefore, to 
be imperfectly performed. It is often asserted that, from exposure to 
cold or other causes, gouty inflammation is apt to subside suddenly, 
and its subsidence to be followed by grave symptoms referable to the 
stomach, heart, or nervous system. This metastatic affection, of which 
our knowledge is in every respect extremely unsatisfactory, is termed 
"retrocedent gout." 

Gout is in general easy of diagnosis ; it may, however, under various 
circumstances, be readily confounded with rheumatism or with rheu- 
matoid arthritis. We do not propose to rediscuss the many pathologi- 

53 



834 



DISEASES OP THE ORGANS OF LOCOMOTION. 



cal and clinical differences which exist between these several affec- 
tions ; but we may recall to mind, as being specially distinctive of 
gout, its tendency to attack the smaller joints and lower extremities in 
the first instance, and mainly the metatarso-phalangeal joint of the 
great toe ; the formation of chalk-stones, not only in connection with 
the joints, but with the perichondrium of the cartilages of the ear and 
eyelids, and in other superficial positions, where they may be easily 
recognized ; and the presence of urate of soda in the blood. Superfi- 
cial uratic concretions may be easily removed, wholly or in part, with 
the point of a lancet and submitted to microscopic examination, when 
they will be found to consist mainly of the characteristic needle-like 
crystals, more or less thickly aggregated. For the purpose of testing 
the condition of the serum of the blood, Dr. Garrod's method may be 
adopted. It is as follows : About two drachms either of the serum 
furnished by the blood on standing, or of the fluid raised by a blister, 
is to be placed in a flat glass dish, somewhat larger than a watch-glass, 
to be acidulated with acetic acid, and to have laid in it an ultimate 
fibre from a piece of linen cloth ; the prepared fluid is then to be 
allowed to stand until by evaporation it has been brought to the con- 
dition of a thin jelly, when, if there have been an undue amount of 
urates in the serum, the fibre will be found, on microscopic examina- 
tion, studded with crystals of uric acid. To confirm the uratic 
character of the concretions removed from the surface of the helix, or 
of the crystals obtained from serum, recourse may be had to the mu- 
rexide test, which consists in the development of a beautiful purple 
color when a small quantity of the crystalline matter is heated with 
nitric acid on a porcelain surface and then treated with ammonia. 

Pathology. — It is, w T e believe, generally now held that, although the 
deposition of urate of soda in the joints and elsewhere furnishes the , 
only trustworthy evidence of the presence of gout, these depositions, 
the various premonitory symptoms, and the almost innumerable con- 
current symptoms, complications, and sequelae, are all traceable to the 
presence of urate of soda in the blood in undue quantity ; that the dis- 
ease, in fact, looking at it from an earlier stage than the joint-affec- 
tion, is to be regarded, not as a disease of the joints, but as an affection 
of the blood, a variety, as Dr. Murchison terms it, of "lithaemia." 
Dr. Murchison, who regards the presence of an excess of urates in the 
blood as the consequence of functional disturbance of the liver, would 
naturally consider gout to have some such relationship to the liver as 
ursemic dropsy has to the kidney. Dr. Garrod, on the other hand, 
apparently inclines to the belief that the kidney, failing from some un- 
known cause to act efficiently in the separation of urates from the j 
blood, is the organ mainly at fault. In the one point of view the ex- 
cess of urate of soda in the blood would be due to simple retention, in 
the other to its excessive formation ; but in either case the deposit of 
this substance in the joints would be regarded as eliminative, and in a \ 
sense curative. Dr. Garrod further regards the inflammation of gouty 
joints as destructive of urates in the blood of the inflamed part, and 
consequently indirectly in the whole mass of the blood. Against these 
hypotheses several important considerations may be adduced. First, | 



GOUT. 



835 



as Dr. Garrod clearly admits, urate of soda is occasionally present in 
the blood in large quantities and yet gout neither is present nor en- 
sues; second, although the presence of this salt in the blood seems to 
have been universally detected during the inflammatory paroxysm of 
acute gout, and during both the exacerbations and remissions of the 
chronic affection, Dr. Garrod points out expressly that it is not present 
during the intervals between the acute attacks, nor during that period 
prior to any attack of inflammation in the course of which its slow 
deposition is taking place in the joints. Surely these facts are more in 
accordance with the hypothesis that the urate is formed in the tissues 
affected and thence shed into the blood, than with that which refers 
the local lesions to the precipitation of this salt from the already over- 
charged blood. We must confess, indeed, that our own views as to the 
pathology of gout are very nearly those which have recently been ad- 
vocated by Dr. Ord. We are inclined to look upon this disease as 
arising from a peculiar tendency to a special form of degeneration in 
certain of the fibroid textures of the body, derived by inheritance or 
acquired by habits of life — a degeneration characterized by the ex- 
cessive formation of urate of soda in the implicated tissues, whence, on 
the one hand, it is discharged into the blood, on the other deposited 
here 'and there and especially in those parts (as cartilage) which are 
least well supplied with vessels and lymphatics. And we are disposed 
to regard the so-called " attacks of gout" as being in some sense acci- 
dental — predisposed to by the gouty deposits which have already accu- 
mulated in the part, and determined by accidental injuries, exposure to 
cold, and generally any of those conditions which are apt to excite local 
inflammations. If this view be correct, we should expect to find a 
specially abundant formation of urate of soda in gouty tissues during 
the period of inflammation in them, and a specially abujidant discharge 
of urates thence into the veins or lymphatics, or both. We know 
that Dr. Garrod's assertion with regard to the absence of urates from 
the serum furnished by blisters applied over the inflamed joint is ap- 
parently opposed to this hypothesis ; on the other hand, Dr. Ord quotes 
•facts which are in its favor; and it must be added that the experimen- 
tum cruris, namely, the chemical examination of the blood obtained 
direct from the veins leading from the inflamed part and its compari- 
son with the blood of other vessels has not yet been performed. 

Treatment. — In reference to the treatment of gout we have to con- 
sider: 1. What should be done during the inflammatory attacks ; 2. 
What should be done during the intervening periods. As regards the 
first question, much difference of opinion prevails. Trousseau, follow- 
ing Sydenham, regards all attempts, local or general, to relieve pain 
or cut short the attack, as prejudicial. These views, however, are not 
generally held, at least in their integrity; and most physicians, we be- 
lieve, would now rarely hesitate to make use of those remedial meas- 
ures the efficacy of which has been proved by experience. The most 
valuable of these is colchicum, which may be given in any of the 
pharmacopceial forms, and of which the wine may be administered in 
doses of from 10 to 30 minims three times a day. Veratria has simi- 
lar but less powerful antipodagral properties. Quinine is another 



836 



DISEASES OF THE ORGANS OF LOCOMOTION. 



remedy the value of which in largish doses, 5 or 10 grains, three times 
a day, has been much lauded. Purgatives are often of great value; 
among such drugs colocynth is believed to be specially efficacious ; and 
indeed the combination of quinine and colocynth forms the basis of 
some of the best-known nostrums. Alkalies, again, especially the 
carbonates or the salts formed by their union with the vegetable acids, 
are generally regarded as useful. The lithia-salts are especially recom- 
mended by Dr. Garrod in consequence of their solvent power over the 
uratic salts. When the inflammatory state of the joints assumes a 
chronic character, the above remedies may be employed, but with less 
vigor ; and at this time guaiacum and especially iodide of potassium 
are often of great value. Generally it may be said that, during the 
gouty paroxysm, the emunctories, especially the kidneys, should be 
encouraged to free action; the bowels should be kept freely open; 
perspiration should be promoted, and the flow of urine increased by 
the drinking of abundant diluents and by the use of the alkaline diu- 
retics. Dyspeptic symptoms should be counteracted, for which pur- 
pose the alkalies are again serviceable; and these, combined with 
colchicum, and either rhubarb or a vegetable bitter, will usually prove 
the most serviceable medicinal agents. As regards local treatment, 
the affected joints should be kept at perfect rest, and if necessary by 
mechanical means. Leeches and cold lotions are generally deprecated, 
and warmth is not always agreeable ; still the investment of the joints 
in cotton-wool, or in bran poultices, sometimes gives comfort, and espe- 
cially the application of blisters, or the wrapping of the parts in flan- 
nel or cotton-wool steeped in rectified spirit and covered with oiled 
silk or gutta-percha. The question, however, of what should be done 
in the intervals to prevent the recurrence of the attacks is the more 
important one; and the answer in general terms is not difficult. The 
patient should make an important reduction in the amount of alcoholic 
stimulants which he is in the habit of taking, or, if he can do so with- 
out detriment to his digestion and to his general health, give them up J 
altogether ; he should refrain from excesses in eating, and especially in 
eating flesh and rich articles of diet; he should, in fact, while not. i 
starving himself or so restricting his choice of viands as to render \ 
food unpalatable, reduce his daily consumption to the amount which 
nature requires, and restrict himself to what is wholesome and nutri- 
tious; he should take daily exercise, not, however, over-fatiguing him- 
self, or insisting on overcoming by exercise the pain or tenderness of an j 
already gout-stricken member; he should dress himself warmly, and 
guard against unnecessary exposure to vicissitudes of temperature; he 
should avoid as far as possible all overwork of the mind as. well as 
of the body, and mental anxiety; further, if he suffer from indigestion 
or other ailment, this should be treated. It may be added that tonics, 
such as iron and quinine, and periodical baths, especially the hot bath, 
the hot air, the vapor, or the Turkish bath, and change of air and 
scene, are often of the greatest value in the treatment of those who suf- 
fer from chronic gout. It must, however, be admitted that the rules 
which are here laid down cannot, unfortunately, be always enforced ; 



RICKETS. 



837 



and, further, that their strict enforcement will, in most cases, diminish 
only, but not eradicate, the gouty tendency. 

It is in cases of this sort that recourse is constantly had to mineral 
waters. There can be no harm in taking alkaline or other waters 
provided the nature of the ingredients contained in them is compatible 
with the patient's requirements. The main benefits, however, which 
result from this practice are due to change of air and scene, to the 
bathing, and to the dietetic and other restrictions which are usually 
enjoined and submitted to. 



EICKETS. {Rachitis.) 

Definition. — This is a disease of early childhood, characterized mainly 
by softening of the bones, with enlargement of the joint-ends of the 
long bones, enlargement of the liver and spleen, and coincident symp- 
toms of general ill health. 

Causation. — Rickets rarely shows itself prior to the sixth month 
after birth, or later than the second year, and most commonly comes 
on between the twelfth and eighteenth month. Children, however, 
are said to have been born rickety, and in rare cases the supervention 
of the disease has been delayed to the fifth or sixth year. Many causes 
have been assigned for rickets, and yet it must be confessed that a good 
deal of mystery still enshrouds its aetiology. It does not appear to be 
hereditary in the sense that rickety children are the offspring of rickety 
parents, or even of parents who are scrofulous or syphilitic ; it never- 
theless happens that rickets is often the appanage of certain families 
of children, and in such cases (according to Sir W. Jenner) it is com- 
mon for the younger members to suffer exclusively, or more severely 
than their elder brothers or sisters. Poverty and hard living would 
seem to exert some influence in its production ; at all events the chil- 
dren of the poorer classes are more frequent sufferers than those who 
are brought up in luxury and comfort. There is no doubt indeed that 
defective hygienic conditions generally favor it ; but among these un- 
suitable feeding is probably by far the most efficient. A large propor- 
tion of rickety children have been brought up by hand, or have derived 
an insufficient quantity of inferior milk from inefficient nurses, and 
have at the same time been supplied with food which is more or less 
unsuitable, or even directly injurious. It is thus, probably, that 
delicate mothers are often indirectly answerable for the rickety state of 
their offspring. The influence of improper diet in the causation of 
rickets seems proved by the experiments conducted by M. Guerin on 
puppies. By removing these animals from the mother, weaning them 
and feeding them on raw flesh (a food unsuited for them at that early 
age), he rendered them, in the course of four or five months, unmis- 
takably rickety. Rickets is said to be especially common in damp and 
cold climates. 

Morbid Anatomy and Pathology. — The morbid changes which attend 



838 DISEASES OF THE ORGANS OF LOCOMOTION. 



and characterize rickets are limited almost exclusively to the bones, 
the liver, and the spleen. And of these by far the most interesting 
and important are those which have their seat in the osseous system. 
The rickety process attacks all bones simultaneously, or nearly so, and 
in about an equal degree. It can, however, be best studied in the 
long bones. In these, the whole tissue tends to become sooner or later 
involved, but those parts in which growth is taking place most actively 
(namely, the extremities and the outer surface) are primarily and 
principally affected. For the following account of the morbid anatomy 
of rickets we are mainly indebted to the investigations of MM. Cornil 
and Ranvier. In the normal process by which ossification extends 
from the already ossified shaft into the cartilaginous end, the line of 
advance is even and well-defined, the cartilaginous tissue immediately 
bounding it (to the thickness of about one-twentieth of an inch) pre- 
senting a peculiar bluish transparent aspect. In this bluish cartilagi- 
nous lamina the changes preliminary to ossification are going on 
actively. But it is in the layer of bone immediately subjacent to it 
that the earliest stage of actual ossification is to be recognized. In the 
former of these laminae we find the encapsuled cartilage cells becoming 
larger and larger at the expense of the surrounding hyaline tissue, and 
giving origin to daughter-cells which themselves become encapsuled, 
but sooner or later yield large numbers of cells having the embryonic 
character. During this process, the cavities in which the cells are 
imbedded increase in size, and presently come to communicate, more 
or less freely, with one another, thus forming branching channels or 
alveoli full of embryonic cells, and separated from one another by 
areolae formed of the surviving remnant of the hyaline matrix. In the 
latter of the laminae above referred to, earthy matter is becoming de- 
posited in the substance of the areolae, and vessels are being developed 
in the alveoli from the embryonic tissue or marrow which they contain. 
A little deeper, the concentric zones of earthy matter and stellate cor- 
puscles which, by their presence within them, convert the alveoli into 
Haversian systems, may be recognized in process of formation. 

In rickets, the bluish cartilaginous lamina becomes very irregular in 
form and thickness, the chief irregularity being manifested by its under 
surface, whence numerous processes extend into the subjacent tissue, in 
which also isolated patches of cartilage may sometimes be detected. 
The chief departure from health, however, is manifested by a lamina, 
corresponding in position to the second of the laminae above described, 
which lies between the layer of cartilage, on the one hand, and the 
ossified extremity of the shaft on the other (from which latter it is more 
or less imperfectly divided), and the thickness of which varies, and in 
some cases is very considerable. This lamina has a marked resemblance 
to sponge, being like it both cavernous and elastic ; but it is highly 
vascular, and its alveoli are filled with a sanguineous pulp. Micro- 
scopic examination reveals the dependence of these abnormal appear- 
ances -upon certain striking modifications of the process of ossification. 
In the bluish cartilaginous . lamina, the mother-cells give origin to 
daughter-cells, which become encapsuled ; but these, while still of large 
size, become incrusted with calcareous granules, which are also depos- 



RICKETS. 



839 



ited in the intervening cartilaginous matrix. Their further prolifera- 
tion is thus to a large extent impeded, and they fail to regulate the 
subsequent process of alveolation, which takes place as it were without 
discrimination — irregular cavities being formed in places by the lique- 
faction of the hyaline cartilage and the contained calcareous capsules, 
and irregular trabecule resulting from the persistence of identical tis- 
sues in the intervals between them. The essential departure from health 
seems so far to consist in calcification of the capsules of the daughter- 
cells, and in the fact that the areola? are formed, not of hyaline material 
only, but of this together with cartilage-cells, which are of large size, 
and incrusted with earthy salts. In the spongy tissue beneath the 
same process goes on ; the alveoli (instead of becoming smaller, as they 
do in healthy ossification, from the formation of concentric laminae) 
become larger and larger, the areolae undergoing corresponding rarefac- 
tion and destruction, and becoming at the same time more and more 
calcareous. The medulla which occupies the cavities is richly provided 
with large delicate-walled vessels, and with an abundance of ordinary 
granulation or embryonic tissue. The morbid processes which go on 
between the shaft and the periosteum are (allowing for the anatomical 
difference between cartilage and periosteum) identical w r ith those just 
described. The periosteum in the normal condition may be readily 
stripped as a membranons lamina from the surface of bone beneath. 
In rickets a soft spongy formation, of various and often considerable 
thickness, intervenes between them. This consists of refractive trabec- 
ule, formed partly of intercellular substance, partly of connective- 
tissue corpuscles, infiltrated to a greater or less extent with earthy mat- 
ter ; and of intercommunicating medullary spaces filled with embryonic 
tissue and new-formed bloodvessels. It is obvious that the areola? or 
trabecular, whether formed out of the cartilage at the epiphysal ex- 
tremities of the bone, or out of periosteum at its surface, and whether 
infiltrated with earthy matter or not, are continuous with the solid 
framework of the completely formed bone-tissue underneath; and that 
the embryonic or granulation-tissue which fills their alveoli is continu- 
ous with the normal medullary matter which fills the Haversian canals, 
the medullary spaces, and the central cavity of the bone. And it may 
be added that, if the rickety condition persist and extend, not only do 
the alveoli of the new-formed tissue enlarge at the expense of the trabec- 
ulse between them, but the medullary tissue of the normal cavities of 
the bone gradually acquires the embyronic character, the bone-tissue 
melts away around it, the Haversian canals and all the other spaces 
consequently undergo enlargement, and general rarefaction ensues. Sir 
W. Jenner observes that the bones of healthy children yield about 37 
per cent, of organic and 63 of earthy matter, whereas those of rickety 
children sometimes yield as much as 79 per cent, of organic and only 
21 of earthy matter. 

The general consequences of rickets are that the bones become in- 
creased in thickness (a change which is especially evident in the joint- 
ends of the long bones and in the edges of the flat bones of the skull), 
and that they become soft, and consequently especially liable to bend or 
break with the so-called u green-stick " fracture. The enlargements of 



840 DISEASES OF THE ORGANS OF LOCOMOTION. 



the ends of bones are most obvious at the wrist and elbow-joints, and 
at those of the ankles and knees ; they are also frequently well devel- 
oped at the junctions of the ribs with the costal cartilages, along the 
lines of the cranial sutures, and elsewhere where bones are in rela- 
tion with epiphysal cartilages. The curvature of the bones comes on 
somewhat later than their manifest thickening, and usually, though not 
invariably, proceeds from the lower part of the skeleton upwards. Its 
direction is determined partly by that of the normal curvatures of the 
bones and partly by the direction and force of the mechanical influences 
which act upon them. The tibia? and fibulse usually bulge forwards and 
outwards, and the femora follow suit ; when, however, the rickety con- 
dition appears late, the curvature of the legs is often in the opposite 
direction, and the child becomes knock-kneed. The radius and ulna for 
the most part acquire a curve with the convexity facing backwards; but 
the curvature of the humerus is often determined by the attachment of 
the deltoid. The shoulders get narrowed by the shortening of the clav- 
icles due to the exaggeration of their natural curves. The back becomes 
bent in accordance with its several curvatures, and often more or less 
twisted. The cervical curve is increased, and the head tends consequently 
to be thrown backwards, and the face to be directed upwards and for- 
wards; and the dorsal and lumbar curves, which are also exaggerated, 
are often attended with lateral deviation connected with rotation of the 
bodies of the vertebra? upon their axes. In children who have not yet 
walked the lumbar curvature is lost in that of the dorsal region, and 
both combine to form the segment of a circle with the concavity look- 
ing forwards. The shape of the chest in rachitic children becomes 
remarkably modified ; the ribs sink in laterally, especially from about 
the third to the ninth, so that the transverse diameter of the chest is 
diminished in this situation, while the antero-posterior is correspond- 
ingly augmented, and the sternum thrown forwards. There is also in 
this portion of the chest a well-marked vertical groove running down 
on either side, just external to the junctions of the ribs with their car- 
tilages. The form of the upper part of the chest, however, is slightly 
or not at all altered ; while the lower part, owing to the pressure of the 
liver and spleen and other abdominal viscera, again expands, and its 
shape is pretty nearly normal. The changes which take place in the 
form of the pelvis are all of great importance. The bones of the upper 
part become flattened and expanded by the pressure of the abdominal 
viscera upon them ; but the weight of the spine above tends to throw 
the sacrum forwards, and the pressure of the femora below to cause an 
approximation of those portions of the pelvis which form the acetabula, 
and the pelvic cavity consequently becomes contracted, and tends to 
assume a triangular form on transverse section. But the relative effects 
of these and other agencies are largely modified in different cases by 
a variety of circumstances, such as age, and the possession and use of 
the powers of walking, crawling, or sitting. The bones of the head 
and face share in the general tendency to deformity. The fontanelles 
are slow in closing, remaining open up to and beyond the second year ; 
the head becomes large, flat on the top, elongated from before back- 
wards, with a projecting forehead, and with unusual prominence of the 



RICKETS. 



841 



frontal and parietal eminences. The teeth are late in making their 
appearance; and indeed if none have been cut by the age of nine months, 
it is a reason for at all events suspecting the presence of rickets. The 
teeth, moreover, are specially apt to decay and become loose. It will 
of course be understood that the deformities of the skeleton in rickety 
children are liable to innumerable variations from the types which have 
been enumerated ; that in a large number of cases they never become 
serious, and are confined probably to the bones of the legs and perhaps 
some few others ; while in some cases they assume such extreme pro- 
portions that they are not only a source of distress and misery, but are 
incompatible with the performance of some of the normal functions of 
life, or even with the maintenance of life. 

After a time, which varies in different cases, the rickety condition 
ceases, and the bones regain their earthy elements and their strength. 
The bone-tissue, indeed, becomes unnaturally strong and dense. In 
some cases slight degrees of curvature slowly disappear during the 
further growth of the bones ; more frequently, however, they are per- 
sistent, and there is more or less of permanent deformity. 

Dr. Dickinson's observations seem to show that a morbid process, 
in some respects like that in the bones, goes on in the kidneys, lym- 
phatic glands, liver and spleen, and especially in the latter two organs, 
of rickety children ; that these organs become enlarged and indurated, 
and the seat partly of interstitial development of fibroid tissue, partly 
of overgrowth of the glandular elements. The changes are transitory, 
and are accompanied by a deficiency of the earthy salts. They are 
quite distinct from amyloid or lardaceous degeneration. 

Whatever the exciting cause of rickets may be, and however it acts, 
there can be little doubt that the morbid processes to which it gives 
rise in the several viscera which have been enumerated and in the 
bones have a close affinity with those of general subacute or chronic 
inflammation, and that the main incidents in them are an irritative 
overgrowth of the implicated tissues, and a modification or perversion 
of their normal nutrition. 

Symptoms and Progress. — In giving an account of the clinical phe- 
nomena of rickets, it is customary to enumerate a long series of pre- 
cursory symptoms, the presence of some or all of which not only 
should excite suspicion of the special impending danger, but are com- 
monly regarded as proofs that rickets is the outcome of some more or 
less long-continued cachexia or dyscrasia. The constitutional origin of 
the malady can scarcely be denied ; but it is certain that the affection 
must always have made some considerable progress before the defor- 
mity of the joint-ends of the long bones or of the chest and the bend- 
ing of limbs becomes obvious, and that many, therefore, of these pre- 
cursory symptoms belong properly to the earlier stages of the rickety 
process. Among these must probably be included catarrhal affections 
of the thoracic viscera and gastro-intestinal disturbance; but by far 
the most important and characteristic are : first, a febrile condition, 
manifested mainly by restlessness at night or during the hours devoted 
to sleep, intolerance of the bedclothes, which the infant continually 
throws off, and profuse perspirations, mainly limited to the head and 



842 



DISEASES OF THE ORGANS OF LOCOMOTION. 



upper parts of the body ; and, second, general tenderness or soreness, 
due doubtless to the general implication of the bones, and indicated by 
a gradually increasing unwillingness or fear to move or to be moved, 
and a loss of enjoyment in the caresses and dancings which form so 
large a part of a healthy infant's life and happiness. The first distinct 
evidence, however, that the bones are undergoing serious change of 
structure is usually afforded by the enlargement of the lower extremi- 
ties of the radius and ulna, and by the simultaneous or shortly sub- 
sequent enlargement of the corresponding portions of the tibia and 
fibula, and of the knee and elbow joints. If the affection still proceed, 
the shafts of the long bones and the spine acquire the alterations of 
form which have been already adverted to; the ribs fall in at the sides, 
the sternum protrudes anteriorly, and the pigeon-breasted condition 
results, in association with which the knob-like enlargement of the 
anterior extremities of the ribs on either side produces that character- 
istic appearance to which the name of the "rickety necklace" or chap- 
let has been applied ; the pelvis gets distorted, and the bones of the 
head become affected, mainly, as has been pointed out, by thickening 
of their edges, protrusion of the parietal and frontal eminences, and 
unusual persistency of the fontanelles. But while all these deforming 
processes are going on with more or less uniformity and rapidity, the 
various symptoms which marked the beginning of the disease usually 
undergo aggravation, the "fever becomes more intense, the pulse accel- 
erated, the heat of skin augmented, the nocturnal perspirations more 
profuse, and the general tenderness more marked. Actual pain, indeed, 
often supervenes, and the fear or inability to move, and the dread of 
being touched, become much more apparent. In connection with these 
phenomena the appetite fails, there are thirst and irregularity of the 
bowels, the urine is copious, and contains a superabundance of phos- 
phates, and the child undergoes rapid emaciation, with disproportionate 
wasting and feebleness of the voluntary muscles; he assumes an anaemic 
or pallid, sad, anxious, wan aspect, and takes no interest in what is J 
going on about him. During all this time the abdomen grows rela- 
tively large, and the liver and spleen will probably be found to be dis- | 
tinctly hypertrophied ; indeed, the enlargement of these organs is some- 
times one of the earliest indications that the child is rachitic. Ascites 
is sometimes a consequence of the hepatic affection. The influence of 
rickets on dentition has been already fully considered. According to 
MM. Pilliet and Barthez, whose opinions are confirmed by those of 
Dr. H. Roger, a blowing sound is so commonly audible over the cranial 
sutures of rachitic children, that it may almost be regarded as diag- 
nostic of the affection. 

[Under the name of craniotabes, Elsasser has described certain changes 
in the bones of the cranium, which, although not alluded to by Sir Wil- 
liam Jenner, are regarded by Virchow as among the unquestionable 
consequences of the rachitic diathesis. This view of their nature was 
accepted by the late Dr. John S. Parry, of Philadelphia, from whose 
masterly essay on Pickets the following condensed description is taken. 
Craniotabes is one of the earliest alterations of the disease, the occipital 
bone becoming thin, and occasionally even perforated^ so that nothing 



RICKETS. 



843 



separates the brain from the inner surface of the scalp but the dura 
mater aud pericranium, which are in contact. In many cases this con- 
dition is found only in this bone, but in patients in whom the disease 
is severe, the posterior margins of the parietal, and in very rare in- 
stances, even the squamous portions of the temporal bones, may be 
involved. The protuberances of the occipital and parietal bones are 
never diseased, the perforations, which in one of Dr. Parry's cases were 
twenty -five in number, being usually situated near the sutural margins 
of these bones, or in those parts of them which are developed from 
membrane, while on the other hand, those which are produced from 
cartilage always, so far as is known, remain healthy. In order to de- 
tect craniotabes, the physician should take a position immediately before 
the child, and placing the heels of his hands upon the temples, care- 
fully examine the upper portion of the occipital and the posterior por- 
tions of the parietal bones with his fingers. If perforations exist, they 
will be easily detected, generally just within the sutural margins. This 
examination should be made very carefully, as, according to Niemeyer, 
pressure upon these soft spots has occasioned convulsions. The vari- 
ous nervous disorders so frequently met with in rachitic children, as, 
for instance, laryngismus stridulus, are attributed by writers to this 
yielding condition of the skull, readily permitting the occurrence of 
pressure upon the brain. These perforations are always preceded by 
thickening and softening of the bone, such as is seen in the frontal and 
in the parietals of rachitic children, and are produced by the pressure 
of the brain on one side, and counter-pressure by the pillow on the 
other. 

The head very frequently in this disease loses its natural rounded 
outline and assumes a square one, which is in accordance with an im- 
portant general law which governs the changes in the rachitic skele- 
ton, and which Dr. Parry formulated as follows. Aside from distor- 
tions by bending or twisting, rachitic bones are characterized by an 
arrest of development, with retention of the foetal type.] 

When rickets proves fatal, it is usually either by gradual asthenia, 
connected with the advance of the disease and impairment of the di- 
gestive functions, or by thoracic complications, such as collapse of the 
lung-tissue, lobular pneumonia, or bronchitis — the accession as well as 
the gravity of which are largely dependent on the weakness, deformity, 
and consequent inefficiency of the thoracic walls. Other causes of 
death in rickety children are laryngismus stridulus, convulsions, and 
chronic hydrocephalus. The duration of rickets commonly ranges 
between six and twelve months, at the end of which time the constitu- 
tional symptoms and those indicative of osseous inflammation subside. 

Persons who have suffered from rickets in infancy not unfrequently 
acquire great strength of limb (muscle and bone), but they usually 
remain of low stature, and the deformities which take place at the 
time of their malady only too commonly persist, while some (more 
especially those of the chest and pelvis) not unfrequently entail serious 
misery and danger in after life. 

In concluding this brief account of the symptoms of rickets, it is 
well to draw attention to the fact that the disease may be present in a 



844 DISEASES OF THE ORGANS OF LOCOMOTION. 



slight degree — sufficient to cause manifest thickening of the wrists 
and ankles, and even bending of the tibise and thoracic walls — in 
children who maintain their vivacity and the aspect of almost perfect 
health. 

Treatment. — It might be supposed, from the fact of the disappear- 
ance of phosphate of lime from the bones, that the administration of 
phosphate of lime is indicated in the treatment of rickets. Experi- 
ence has not, however, confirmed this view, nor, indeed, does a cor- 
rect interpretation of the pathological phenomena of the disease give 
it any sanction. The best medicinal remedies are tonics, such as iron 
and cinchona, and, above all, cod-liver oil. But these are valueless 
without the most careful attention to diet and to hygiene. The diet 
should be at once nutritious, sufficiently abundant, and adapted to the 
age and circumstances of the child. For the young infant nothing 
can be more suitable than the healthy breast, or, failing that, asses' 
milk, or. else cows' milk, or preserved Swiss milk, properly diluted, 
and mixed, it may be, with a certain proportion of biscuit powder. At 
a later age a moderate quantity of well-cooked meat, comprised in a 
dietary which combines all the other essential elements of food, namely, 
sugar, starch, and fat, and composed, therefore, largely of milk and 
bread and butter, should be administered. The child should be 
warmly clad, should occupy an airy but sufficiently warm room, be 
regularly bathed and well rubbed afterwards, and taken out habitu- 
ally into the open air. Change of air, and especially residence on the 
seacoast, are often of essential service. But, in addition to the above 
measures, it may be desirable to treat the symptoms which are so apt 
to accompany rickets, to improve the condition of the stomach, to 
regulate the action of the bowels, to reduce fever, and to combat pul- 
monary and other complications, and especially it is of paramount 
importance to prevent, as far as we possibly can, the supervention of 
deformity. To this latter end our measures must be regulated by the 
age and peculiarities of the patient. It is impossible to go into detail 
without becoming unsuitably diffuse. We may, however, point out, 
that the child should lie on a soft, well-made feather bed, that if it be 
quite young, it should not be allowed to sit up, and that if older (and 
the limbs give evidence of bending), it should be prevented from walk- 
ing, and perhaps even from crawling. Mechanical appliances may be 
necessary to prevent undue locomotion. 



MOLLITIES OSSEUM. (Osteo-malacia.) 

Definition and Causation. — This is an affection having in many 
respects a close resemblance to rickets. It occurs, however, not in 
children, but in adults. It has been recognized, indeed, only in 
women, and for the most part in women who are bearing children. 

Morbid Anatomy and Pathology. — Mollities ossium is characterized 
anatomically by progressive softening of the bones, sometimes of those 



MOLLITIES OSSIUM. 845 

of the whole skeleton, occasionally of a limited number only. The 
j minute changes appear to consist mainly in a progressive decalcification 
of the bony tissue, commencing from the Haversian canals and medul- 
lary spaces, and gradually involving the successive lamina of bone 
which surround them, until finally decalcification is complete. A sharp 
line generally marks the limit of the morbid process, the bone external 
to it being still normal, whilst that between it and the canal or cavity 
is converted into a kind of fibroid tissue, in which the bone-corpuscles 
are scarcely distinguishable. At a later period the portions of tissue 
first affected soften and liquefy. Attending these changes the smaller 
vessels become dilated, and the contents of the various cavities red and 
pulpy. The enfeebled bones are liable to all those bendings and im- 
perfect fractures which also characterize rickety bones ; but, owing to 
the long duration of the malady and the extent to which softening takes 
place, the deformity which ensues is usually of the most aggravated 
kind and pretty universal. Trousseau maintains that mollities ossium 
is identical with rickets, allowance being made for difference of age and 
for the fact that the active processes of growth have ceased when osteo- 
malacia makes its appearance. The anatomical details, however, of the 
two processes are manifestly different. It is supposed by Rindfleisch 
and some others that the decalcification is due to the action of some 
acid (carbonic or lactic) contained in the blood. The appearances are, 
no doubt, much like those which might be thus caused. There is no 
direct evidence, however, to support this view ; and indeed Virchow 
has ascertained the existence of a strong alkaline reaction in the gela- 
tin yielded by fresh bones affected with this disease. 

Symptoms and Progress. — The symptoms of osteo-malacia, like those 
of rickets, are often very insidious ; and the disease may first reveal its 
presence by the occurrence of deformity and fracture of bones. The 
progress of the disease is, however, usually attended, even from the 
first, with febrile disturbance and copious perspirations, and with ten- 
derness and pain in the course of the affected bones. The pains are, in 
the first instance, vague and wandering, and of a shooting character. 
They gradually become, however, more or less intense ; affect not only 
the limbs, but the trunk, the head, and the face ; and are greatly aggra- 
vated by movement or by pressure. They are often most severe in the 
joint-ends of long bones, and in the epiphysal ends of most bones. 
They may easily be mistaken at first for rheumatic or neuralgic pains. 
The urine contains an excess of phosphate of lime. 

The progress of osteo-malacia is chronic ; cases have been met with 
in which the disease has been prolonged for fourteen or fifteen years 
and upwards. Death usually takes place, however, at a much earlier 
date, and is generally due immediately to interference with the respira- 
tory or circulatory functions. Recovery very rarely takes place, and 
never without persistent deformity. Trousseau has recorded a case or 
two of this kind. 

Treatment. — No distinction need be drawn between the treatment of 
osteo-malacia and that of rickets. It was under the use of cod-liver 
oil that Trousseau's cases recovered. 



846 



DISEASES OF THE ORGANS OF LOCOMOTION. 



PSEUDOHYPERTROPHIC PARALYSIS. 

Definition, — This is a form of paralysis, first recognized and described 
by M. Duchenne, occurring in children, and attended with remarkable 
enlargement of some of the paralyzed muscles. 

Causation. — It has hitherto been observed in childhood only, and 
almost exclusively in boys It has been met with also in several 
children of the same family. But beyond these facts nothing whatever 
is known in reference to its causation. 

Morbid Anatomy. — The morbid process, so far as the muscles are 
concerned, appears to consist mainly in the gradual growth of con- 
nective tissues in the interstices between the ultimate fibres; this be- 
comes abundant and dense, and in some cases the seat also of the 
formation of fat. It is to this overgrowth that the apparent hyper- 
trophy of the muscles is due. The muscular fibres appear to dwindle 
away under the influence of the pressure to which they are subjected ; 
and, although retaining their transverse striation for a long period, at 
length undergo degenerative changes : the transverse markings become 
indistinct, or effaced, longitudinal markings perhaps unusually appar- 
ent, and more or less abundant deposit of granular or fatty matter 
takes place. The condition of the muscles in the earliest stage of the 
disease has been less thoroughly investigated than their condition in 
the later periods. M. Duchenne believes that at that time there is an 
oedematous state of the tissue which itself causes a certain amount of 
increase of volume. 

Symptoms and Progress. — The course of pseud o-hypertrophic par- 
alysis has been divided by M. Ducheime into three periods. Of the 
first period but little is certainly known, for the symptoms are then 
slight, and children are rarely at that time brought under medical 
treatment; moreover the symptoms are in no degree distinctive of the 
disease, and are apt therefore to be misunderstood. The first symptoms 
appear to be due to gradual enfeeblement of the muscles of the lower 
extremities, and perhaps of those of the back. The child presents cer- 
tain peculiarities of gait. He stands with his legs widely separated, 
and his shoulders thrown back, probably beyond the buttocks, the con- 
cavity of the small of the back being correspondingly deepened ; he 
walks also with his legs apart, lifting the knee of his advancing leg 
needlessly high, while the foot is more or less extended, and the toes 
point downwards, and swaying his body from side to side in association 
with the peculiar position and movement of his lower extremities. 
This stage, according to M. Duchenne, usually varies in duration from 
a few months to a year. It may, however, be delayed, or it may so 
speedily merge in the second stage as to be unappreciable. 

The second stage is marked by the gradual extension of the disease 
and the enlargement of certain of the muscles. The paresis, which 
probably always commences symmetrically in the lower extremities, 
gradually mounts, involving successively the muscles of the back and 
of the trunk generally, the muscles of the arms, and in some cases 



PSEUDOHYPERTROPHIC PARALYSIS. 



847 



those of the face — more especially the temporals and masseters. Pos- 
sibly some fulness of the calves may have been already apparent in the 
first stage ; but now they augment rapidly and considerably in volume 
and by degrees various other groups of muscles become similarly 
affected. The degree of enlargement and its distribution differ very 
greatly in different cases. In some, only the calves become hypertro- 
phied, while the muscles of the rest of the body either retain their 
normal bulk, or shrink ; in some the calves and buttocks are the chief 
seats of overgrowth ; in some the increase of bulk involves all the 
muscles of the lower extremities together with the posterior muscles of 
the spine ; in some, again, the deltoids share in the widely-diffused 
hypertrophy; and occasionally all the muscles of the limbs and trunk 
become enormously increased in volume, and the child (though so 
feeble, perhaps, that he can scarcely move) has the appearance of an 
infant Hercules. This enlargement of the muscles, even if it be limited 
to the calves, is a very striking phenomenon ; especially when, as in 
these cases, it goes along with progressive loss of muscular power. 
During the progress of this stage the phenomena which have already 
been referred to as attending the acts of standing and walking become 
more pronounced; the legs are kept widely apart; the shoulders are 
thrown far backwards; and the peculiar swaying of the body from 
side to side which attends the efforts to raise and project the legs 
successively forwards, becomes considerably exaggerated. Moreover, 
the child has the greatest difficulty in rising from the ground on which 
he is sitting into the upright posture; he gets on all-fours, then pro- 
trudes his buttocks like a dog in the act of stretching, and probably 
finds all his efforts fruitless unless he can manage to raise his head 
and shoulders hand over hand by means of a chair or bedstead. This 
stage attains its full development in a year or a year and a half, and 
may then continue with little change for two or three years more. 

The third stage is characterized by extension of paralysis to the 
upper extremities, supposing these to have escaped hitherto ; by arrest 
of the progressive enlargement of the muscles ; and possibly even by 
their diminution. The child grows more and more helpless; the vol- 
untary elevation of the arms becomes difficult and at length impossible 
and he gradually loses all power in his lower extremities, and is hence 
condemned to pass the rest of his existence on his chair or in bed. 
Since respiration, circulation, and digestion remain unaffected, life may 
be sustained in this condition for a considerable period ; but sooner or 
later the vital powers of the patient become prostrated, and pneumonia 
or some other intercurrent affection carries him off. Death usually 
occurs during the period of adolescence. 

In order to complete the picture of the disease, two or three other 
facts in relation to these patients must be mentioned. ISTo febrile 
symptoms manifest themselves at any period of the disease. The 
muscles in the early stage retain their electro-contractility almost 
unimpaired ; but later on, as the muscular fibres undergo degenera- 
tion, electro-contractility also necessarily dies out. It has been shown 
by Dr. Ord that (as in infantile paralysis) the temperature of the 
affected limbs becomes diminished. It has often been observed that 



848 



DISEASES OF THE NERVOUS SYSTEM. 



children afflicted with this disease are or become defective in their 
intelligence; and that if they be attacked before they have learnt to 
speak they are slow in learning to speak, and imperfect in their articu- 
lation. Lastly there is no impairment of sensation, and no loss of 
control over the bladder or rectum. 

Pathology. — Notwithstanding the symmetrical character of pseudo- 
hypertrophic palsy , its tendency to become generalized, and its associa- 
tion with impaired intelligence, there is no sufficient reason to regard 
it as of nervous origin. For no lesions whatever have been detected 
in the nervous centres or in the nerves ; while the absence of rigidity, 
of incoordination, and of rapid wasting, and the retention of sensation, 
of control over the sphincters, and of muscular contractility, equally 
point to the integrity of the spinal cord. On the other hand, in the 
muscles themselves progressive changes have been discovered which 
are ample to explain the main phenomena of the disease. 

Treatment — According toM. Duchenne pseudo-hypertrophic paralysis 
may sometimes be cured or arrested in its first stage by muscular fara- 
dization, aided by baths and kneading, or shampooing. When once, 
however, distinct enlargement of muscles has taken place, no treatment 
that has yet been adopted avails to delay the fatal progress of the 
disease. 



Vm. — DISEASES OF THE NERVOUS SYSTEM. 

INTRODUCTORY REMARKS. 

Anatomy and Physiology. 

The nervous system comprises the cerebrum and cerebellum, with 
the various ganglia and commissures which belong to these bodies, the 
medulla oblongata, the spinal cord, the sympathetic ganglia, and the 
nerves which, springing from these several sources, are distributed 
throughout the organism. With the central organs are associated as 
important elements the various membranes and other structures which 
serve for their support and protection, and the arteries and veins which 
minister to their nutrition and functional activity. 

Membranes of Brain and Cord. — The cranial dura mater is a thick, 
dense, inelastic fibrous membrane, which by its outer surface adheres 
firmly to the inner aspect of the bones of the skull, by its inner sur- 
face, which is smooth and polished, constitutes the parietal limit of the 
arachnoid cavity. It forms also certain septa, needless to specify, 
which intervene between both the cerebrum and cerebellum and their 
respective hemispheres. At the foramina for the exit of the nerves at 
the base of the skull the dura mater becomes continuous on the one 
hand with the pericranium, on the other with the sheaths of the nerves. 
The spinal dura mater, which, like the cranial, is dense, thick, and 



ANATOMY AND PHYSIOLOGY. 



849 



inelastic, is prolonged in the form of a loose bag from the margins of 
the foramen magnum, to which it is adherent, to the first or second 
sacral vertebra, where, blending with the filum terminate of the cord, 
it is continued onwards therewith to the lower end of the sacral canal. 
The spinal dura mater is separated on all sides from the bony cavity 
in which it lies by fat and areolar tissue. Its internal surface is smooth 
and polished, and presents along either side a double series of orifices 
of which each contiguous pair gives exit to the anterior and posterior 
roots of one of the spinal nerves. The dura mater is continued on 
each nerve as a tubular prolongation, within which the ganglion of the 
posterior root is contained. It then blends with the sheath of the 
nerve and becomes connected by fibrous processes with the margins of 
the intervertebral foramina. 

The arachnoid cavity is usually regarded as a serous cavity. It 
occupies the interval between the dura mater, on the one hand, and the 
general surface of the brain and cord upon the other, being perfectly 
continuous throughout. Its outer limit is represented by the smooth 
inner aspect of the dura mater; its inner limit is formed by a delicate 
transparent membrane which lies loosely upon the surface of the cen- 
tral organs, never dipping into the sulci, and lying especially loosely 
upon the parts situated at the base of the brain, and upon the spinal 
cord. The inner and outer aspects become continuous by means of 
tubular prolongations wherever nerves or vessels pass from the protec- 
tive organs without to the central nervous organs within. 

The pia mater is the vascular membrane which closely invests the 
outer surface of the brain and cord, following all its inequalities. It is 
continuous by its applied surface with the connective web and the vas- 
cular network which pervade the substance of the subjacent organs, 
and the neurilemma of the nerves appears to be derived from it. The 
pia mater within the skull is delicate and highly vascular, dips to the 
bottom of all sulci, and accurately fits the complicated arrangement of 
processes and depressions which exist at the base of the brain. It dips 
also into the great transverse fissure of the brain and into the some- 
what similar fissure existing behind between the medulla and the cere- 
bellum, forming in either situation a reduplication, the free margins of 
which are wrinkled and folded, and constitute the bodies which are 
known as the choroid plexuses. The pia mater of the cord is much 
thicker, denser, and less vascular than that of the brain, forms in front 
a duplicature which dips to the bottom of the anterior furrow, and be- 
hind a thin vertical septum which occupies the posterior furrow. 

The interval which exists between the pia mater and the visceral 
! lamina of the arachnoid is known as the subarachnoid space; it is 
j crossed by numerous delicate fibrous bands, and in the spinal canal on 
, either side by the ligamentum denticulaturn and behind by an incom- 
! plete vertical septum. It is the seat of the subarachnoid fluid which 
| constitutes the great bulk of the cerebro-spinal fluid. 

Ventricles of Brain and Cord. — The existence of the ventricles of the 
brain and cord (excepting the fifth) as distinct cavities is due in some 
I sense to the failure already referred to of the pia mater at the great 
transverse fissure of the brain and at the posterior part of the fourth 

54 



850 



DISEASES OF THE NERVOUS SYSTEM. 



ventricle to follow the various diverticula or involutions which take 
their origin in these situations. The system of ventricles comprises 
the lateral ventricles, which are continuous with one another and with 
the third ventricle in the interval between the fornix above and the 
optic thalami below, into which the velum interpositum extends ; the 
third ventricle, which communicates by means of the iter with the 
fourth ventricle; the fourth ventricle; and the central canal of the 
cord, which commences above at the calamus scriptorius or posterior 
extremity of the fourth ventricle. The nervous boundaries of the ven- 
tricles are covered with a delicate membrane which is continuous with 
the neuroglia or connective web permeating the substance of the sub- 
jacent organs, is identical in structure with it and is furnished with an 
epithelium. The ventricles form a continuous system, and have no 
communication with other cavities or spaces, excepting, as was pointed 
out by Magendie, with the subarachnoid space by means of a small 
opening situated at the lower extremity of the fourth ventricle. 

Cerebral Hemispheres. — The cerebrum consists of two hemispheres, 
separated the one from the other above by the great longitudinal fissure, 
and united one with the other below mainly by means of the commis- 
sural fibres of the corpus callosum, by the fornix and certain other 
structures which need not be specified. It is composed of white and 
gray matter, of which the one forms a comparatively thin lamina on 
the surface, while the other makes up the great bulk of its mass. The 
surface of the organ, and with it of course the gray matter, is arranged 
in folds or convolutions, separated by fissures or sulci, the more im- 
portant of both of which present a tolerably definite and regular 
arrangement. The gray matter of the convolutions is doubtless the 
seat of the intellectual and emotional functions and the source of those 
various combined muscular actions which accompany and reveal their 
operation. The study of the convolutions is, therefore, a matter of 
interest, even though but little is as yet known in reference to their re- 
spective functions. That little, however, is important ; and we proceed 
to describe so much of the topography of the cerebral surface as will 
enable us to make that little intelligible. 

1. Sulci. — The fissure of Sylvius commences on the base of the brain 
at the locus perforatus anticus, and, separating the middle from the 
anterior cerebral lobe, passes directly outwards until it reaches the 
lateral aspect of the hemisphere. Here it divides into two branches : 
an anterior short branch, which proceeds upwards and forwards, and a 
posterior long branch, which courses nearly horizontally backwards 
upon the outer surface, dividing the temporal lobe below from the 
parietal lobe above. The fissure of Rolando, or sulcus centralis, com- 
mencing above at the great longitudinal fissure a little behind the 
vertex, runs downwards and forwards over the outer surface of the 
hemisphere to near the point of bifurcation of the Sylvian fissure, sep- 
arating the frontal lobe in front from the parietal lobe behind. The 
interparietal fissure, originating in the angle contained between the fis- 
sure of Rolando and the posterior Sylvian branch, passes irregularly 
backwards towards the parietooccipital fissure. The parallel or first 
temporal fissure, running parallel to but below the posterior Sylvian 



ANATOMY AND PHYSIOLOGY. 



851 



branch, turns up behind its posterior extremity, and there loses itself 
in a group of convolutions which are limited above and behind by the 
posterior part of the interparietal fissure, and are known by the name 
of the gyrus angularis or pli courbe. On the inner aspect of each 
hemisphere there are two fissures which call for special notice : one is 
thefronto-parietal, which, commencing in front, runs backwards parallel 
with the corpus callosum, forming the upper limit of the gyrus forni- 
catus, until having arrived near the posterior edge of the corpus callo- 
sum, it turns up to reach the upper margin of the hemisphere a little 
behind the upper termination of the fissure of Rolando ; the other is 
the vertical or parieto-occipital, which, commencing on a level with the 
posterior extremity of the parallel sulcus, runs downwards and forwards 
until uniting with the calcarine fissure to form the hippocampal fissure, 
it ends below the posterior border of the corpus callosum. It separates 
the occipital from the parietal lobe. 

2. Convolutions. — In front of the fissure of Rolando, and following 
its course from below upwards, runs the ascending frontal or anterior 
parietal convolution ; and from the anterior aspect of this are given 
off in succession from above downwards the first, second, and third 
frontal convolutions. The first of these runs parallel with the longi- 
tudinal fissure, and forms, indeed, the marginal convolution of that 
fissure ; the second follows the same course as the first, but lies external 
to it; and the third, still more external, by its posterior part forms the 
upper and anterior boundary of the anterior branch of the fissure of 
Sylvius, and by its anterior part separates the second convolution 
above from the external orbital convolution below. The third frontal 
convolution of the left side is also called Broca's convolution. The 
orbital convolutions occupy that portion of the under surface of the an- 
terior cerebral lobe which lies upon the floor of the skull. Parallel to 
the ascending frontal convolution, and separated from it by the fissure 
of Rolando, courses the ascending parietal convolution, from the pos- 
terior and outer margin of which two secondary convolutions, separated 
from one another by the interparietal sulcus, pass nearly directly back- 
wards ; the inner and upper one, the gyrus supra marginalis or superior 
parietal convolution, forming the margin of the longitudinal fissure in 
this situation, and ending behind at the parieto-occipital fissure ; the 
outer or lower one lying, at its anterior extremity, mainly between the 
interparietal sulcus and the posterior branch of the fissure of Sylvius, 
and further back between the interparietal sulcus and the posterior 
extremities of the Sylvian and first temporal fissures. In the latter 
part of its course it is considerably curved, and receives the name of 
gyrus angularis, or pli courbe. There are three temporal convolutions 
passing nearly horizontally backwards from the anterior part of the 
temporal lobe ; the first is situated between the posterior branch of the 
Sylvian fissure above and the first temporal fissure below ; the second 
lies below the first temporal fissure; the third is lower dowm, but 
parallel with the others. At the bottom of the fissure of Sylvius, at 
its point of bifurcation, and concealed by the overlying convolutions, 
lies the island of Reil, the gray matter of which is in close anatomical 
relation in front with that of the posterior part of the third frontal 



852 



DISEASES OF THE NERVOUS SYSTEM. 



convolution, behind with that of the first temporal. For an account 
of the remaining convolutions, to some of which we may subsequently, 
allude incidentally, we must refer to anatomical works. 

3. Functions of Surface of Brain. — It is in the posterior extremity 
of the third frontal convolution of the left side, or in Broca's convolu- 
tion, that, judging from pathological evidence, the faculty of articulate 
language resides. Terrier's experiments on the lower animals appear 
to show that electrical excitation of certain parts of the cerebral surface 
invariably produces specific combined movements: that irritation of the 
posterior part of the third frontal and of the neighboring part of the 
ascending frontal causes movements in the tongue and jaws; that irri- 
tation of the posterior extremity of the second frontal and adjoining 
part of the ascending frontal provokes movements of the muscles of the 
face ; that irritation of the posterior extremity of the first frontal evokes 
rotatory movements of the head and neck ; and that irritation of the 
anterior extremity of the first temporal convolution causes movements 
of the ears, while irritation of its posterior extremity or of the pli courbe 
determines certain movements of the eyes. Further, a circumscribed 
area, comprising the upper extremities of the ascending frontal aud 
ascending parietal convolutions, would seem on the same grounds 
to be the centre for the movements of the upper extremity, and the 
first or superior parietal convolution the centre for the movements of 
the lower extremity. It need scarcely be said that these facts are of 
great interest in reference to the determination of the locality of 
cerebral disease, attended with motor phenomena. It must, however, 
be added that Drs. Dupuy and Burdon Sanderson have recently 
shown that the specific motor powers above referred to do not reside 
absolutely in the gray matter of the convolutions; but that in each 
case similar effects may be produced by exciting, after successive re- 
movals, each successive fresh surface of that wedge of brain-substance 
of which the base corresponds to the particular superficial motor area, 
and the apex to a point in the corpus striatum. Dr. Sanderson, indeed, 
says that the movements are produced most distinctly when the irri- 
tation is effected directly upon the corpus striatum. 

In reference to this subject it may further be observed that M. Betz 
has recently shown that the surface of the cerebrum may be divided 
by microscopic peculiarities into two regions, of which the anterior, 
limited by and including the ascending parietal convolution, is charac- 
terized by containing, in greater or less abundance, giant cells resem- 
bling those of the anterior cornua of the spinal cord, the posterior by an 
almost total absence of such cells. It is an interesting fact that the 
giant cells are found most abundantly in the ascending frontal and 
ascending parietal convolutions and parts in their immediate neighbor- 
hood which contain Ferrier's centres of movement for the upper and 
lower extremities, and in the prcecentral lobule which is formed on the 
inner aspect of the hemisphere by the junction of these same convolu- 
tions, and is bounded there below and behind by the fronto-parietal 
fissure. It seems probable, therefore, both on anatomical and experi- 
mental grounds, that the anterior and upper portion of the surface of 
the brain is more particularly connected with the psychomotor func- 



ANATOMY AND PHYSIOLOGY. 



853 



tions ; and that the posterior and lower portion is, as M. Betz suggests, 
and as has been long suspected, the seat of the sensorium. 

Ganglia at Base of Brain. — Excepting the commissural fibres of the 
corpus callosum and fornix, and certain other commissures, which need 
not be enumerated, all the nerve-fibres from the gray matter of the con- 
volutions converge to the group of ganglia situated at the base of the 
brain, namely, the corpora striata and the optic thalami, together with 
the corpora geniculata and corpora quadrigemina, and are thence con- 
tinued (directly or indirectly) either through the superior cerebellar 
peduncles to the cerebellum or along the crura cerebri to the medulla 
oblongata. Each striated body comprises three nuclei, separated from 
one another by white fibres. The first of these is the caudate nucleus, 
and is that portion of the body which is visible in the lateral ventricle. 
The second is the lenticular nucleus, which is placed in part external 
to and below the caudate nucleus, in part external to and below the 
optic thalamus : being separated from these bodies by a layer of white 
fibres, which forms the internal capsule, and on the outer side from the 
gray matter of the island of Reil by a similar white lamina, which is 
known as the external capsule. Imbedded in this last is the third or 
tceniceform nucleus or claustrum, which forms an exceedingly thin plate. 
The cerebral fibres which enter these nuclei and occupy the intervals 
between them come from all parts of the cerebral surface, but mainly 
from the anterior half, including the island of Reil and its neighbor- 
hood ; and those which emerge from them below pass mainly down- 
wards and backwards to form the under portion or crust of the corre- 
sponding cerebral peduncle within which they become connected with 
an additional ganglion of the same system, namely, the locus, niger. 
The further destination of the crust is twofold ; it sinks into the anterior 
and upper edge of the pons, and there divides into two portions, of 
which one, according to Meynert, crosses among the anterior fibres 
of the pons, and passes with these to the opposite half of the cerebellum, 
thus decussating with its fellow ; while the other emerges from the 
posterior border of the pons as the anterior pyramid, which also decus- 
sates with its fellow, and is prolonged mainly to form the lateral column 
of the opposite side of the cord. 

The optic thalami, corpora geniculata, and corpora quadrigemina 
also derive fibres from nearly all parts of the cerebral surface, though 
mainly probably from the posterior and lateral portions, and, resting 
by their under surface upon the cerebral peduncles, are more or less 
directly continuous with their upper half or the tegmentum. This, 
which includes within it the red nucleus, divides like the crust into 
two portions. One of these continues backwards as the processus e 
cerebello ad testes and valve of Vieussens to form the superior peduncles 
of the cerebellum ; and the fibres which constitute it for the most part 
decussate anteriorly to the posterior limit of the testes, and so reach 
the opposite sides of the cerebellum. The other continues downwards, 
in the substance of the pons and on the floor of the fourth ventricle, to 
become continuous mainly with the sensory tracts of the medulla ob- 
longata and cord. 

Cerebellum and its Peduncles. — So little is known comparatively of 



854 



DISEASES OF THE NERVOUS SYSTEM. 



I 



the specific functions of different parts of the cerebellum, that it is 
needless to consider here either its general form and arrangement, or 
the names which have been given to its separate lobes and lobules. It 
may, however, be pointed out that, in addition to its superficial gray 
investment, it contains imbedded in its white medulla in the first place 
two ganglia (one on either side), the corpora dentata, and in the next 
place two other gray nuclei, the roof nuclei of Stilling, which lie below 
the central lobule of the superior vermiform process. 

The cerebellum presents three pairs of peduncles or groups of white 
fibres, of which one comes from the cerebrum, one from the medulla 
oblongata, and the other is mainly transversely commissural. The 
first, or superior peduncles, come almost exclusively from the tegmen- 
tum of the cerebral peduncles, comprise the processus e cerebello ad 
testes with the intermediate valve of Vieussens, and pass into the cor- 
pora dentata and thence to the convolutions. The second, or middle 
peduncles, are constituted mainly by the transverse fibres which form ■ 
the great bulk of the pons Varolii, but comprise the cerebellar fibres 
derived from the crust of the cerebral peduncles ; of these the more 
internal pass into the roof nuclei, but the outermost, accompanied by 
the restiform bodies, reach the surface of the cerebellum without the 
intermediation of either of these ganglia. The third, or inferior pedun- 
cles, are the restiform bodies. 

It will thus be seen that the most direct, if not the only, communi- 
cation between the hemispheres of the cerebrum and those of the cere- 
bellum is effected by means of fibres which, taking their origin in the 
cerebral ganglia, pass backwards and lose themselves probably in the 
ganglia imbedded in the white substance of the cerebellum, that of 
these some are derived from the crust, some from the tegmentum, of 
the crura cerebri, and that all, according to Meynert, decussate in the 
course of their passage. It will also be gathered that both the cere- 
brum and cerebellum send down strands of fibres to take part in the 
formation of the medulla oblongata. Those from the brain are con- 
tinued from both layers of the crura cerebri; those from the cerebellum 
are the restiform bodies. 

Spinal Cord. — Before speaking further of the medulla oblongata, it 
will be well to describe the spinal cord. This, which extends, in the 
adult, from the foramen magnum above to the lower part of the first 
lumbar vertebra below, presents an anterior and posterior median 
fissure, and besides these, two lateral furrows, which correspond to the 
successive points of emergence of the anterior and posterior roots. It 
is thus divided superficially, on each side, into a posterior, a lateral, 
and an anterior column. But, in addition to these, a slender median 
column, most obvious in the upper part of the cord, may be observed 
running along the edge of the posterior median fissure. On transverse 
section the gray matter of the cord will be found to occupy its central 
part, the white its periphery. The gray matter is arranged in the 
form of two lateral crescents, placed back to back, and united with 
one another in the middle by a transverse commissure, which crosses 
the narrow interval between the bottoms of the anterior and posterior 
fissures, and contains within it the ventricle of the cord. The poste- 



ANATOMY AND PHYSIOLOGY. 



855 



rior limb of each crescent constitutes the posterior horn of gray matter, 
the anterior limb the anterior horn. In the latter are situated several 
distinct groups of large multipolar cells, which appear to be the nuclei 
of origin of the anterior or motor nerves, and from it the root of each 
nerve passes forwards through the substance of the white matter in 
several parallel bands. The posterior horn is tipped by an area which 
is known as the gelatinous substance of Rolando, from the whole ex- 
tent of which the fibres of each posterior root escape in wavy bands, 
some undulating through the substance of the adjoining posterior 
column previous to their appearance at the surface of the cord. At 
the root of the posterior cornu, on its outer side, is the group of cells 
which indicates the longitudinal tract to which Lockhart Clarke has 
given the name of tractus intermedio-lateraUs, and in almost the cor- 
responding situation, on its inner side, may be seen the sectional surface 
of the tract of cells which constitute Clarke's posterior vesicular column. 
The gray matter varies in bulk in different parts of the cord, and is 
especially abundant in the cervical and lumbar enlargements, but the 
superficial white matter increases absolutely in quantity from below 
upw r ards. 

Medulla Oblongata. — At the upper part of the cord, where it merges 
in the medulla oblongata, considerable changes are presented in the 
distribution of its parts. These changes become more and more 
remarkable as we proceed from the lower to the upper part of the 
medulla oblongata, and are complicated by the appearance of addi- 
tional gray nuclei. The posterior fissure opens out and blends with 
the ventricle of the cord ; the posterior pyramids are divaricated, form- 
ing between them the calamus scriptorius, and the rest of the posterior 
columns, now constituting the restiform bodies, pass upwards and out- 
wards to form the inferior peduncles of the cerebellum ; in front of 
these is gradually developed, on either side, a gray column, due to the 
altered position of the gelatinous substance of Rolando; still further 
forwards we see the apparent blending of each lateral column with its 
olivary body, and in front the anterior columns, apparently continued 
upwards into the anterior pyramids. The arrangement of parts here is 
exceedingly complicated ; but it may be stated generally that the bulk 
of each posterior column of the cord passes upwards in the restiform 
body without decussation to the cerebellum ; that the greater part of 
the white substance of each antero-lateral column decussates with the 
corresponding part of the opposite side at the lower extremity of the 
anterior pyramid; and that each pyramid is hence constituted mainly 
by the continuation upwards of the medullary matter of the opposite 
side of the cord to that on which it is itself situated, and then, passing 
through the substance of the pons Varolii, forms in front of it the 
larger bulk of the crust of the corresponding cerebral peduncle; and 
lastly, that some portion of the fibres of the lateral columns, and most 
of the opened-out gray matter of the cord, pass upwards along the 
floor of the fourth ventricle and along the back of the pons Varolii, 
partly to form the tegmentum, partly to become associated with the 
gray matter of the iter and third ventricle. 

Cerebrospinal Nerves. — The cerebro-spinal nerves, with only two 



856 



DISEASES OF THE NERVOUS SYSTEM. 



exceptions, originate in the gray matter of the spinal cord, or its con- 1 
tinuations in the medal la oblongata, along the floor of the fourth ven- 
tricle, and around the iter. They are of two kinds, motor and sensory. 
The motor spinal nerves have their immediate origin in the groups of 1 
large cells contained in the anterior cornua, and emerge at the surface 
of the cord in the furrow separating the anterior from the lateral col- 
umns ; the sensory nerves originate apparently in the posterior cornua, 
and make their appearance superficially in the groove which divides 
the lateral from the posterior columns. 

The cerebral nerves, in the main, arise according to their properties 
in the upward continuations of the motor and sensory tracts of the gray 
matter of the cord ; in other words, the motor nerves spring from the 
upward continuation of that portion of gray matter which is anterior 
to the spinal ventricle, the sensory nerves from the upward continua- 
tion of that portion which is behind it. But these tracts, as has been 
shown, become modified in their relative positions in the medulla ob- 
longata and floor of the fourth ventricle ; the motor tract becomes super- 
ficial on either side of the median line in the course of the fasciculi 
teretes; the sensory tract, on the other hand, split into two halves, con- 
tinues upwards on either side of the motor tract, occupying each lateral 
half of the floor of the ventricle, spreading out on either side along the 
inner aspect of the cerebellar peduncles towards the cerebellum, and at 
the anterior point of the fourth ventricle rising up and coalescing again, 
as in the cord, over the iter or tubular continuation of the ventricle. 
The motor nerves, in their order from behind forwards, are the spinal 
accessory and hypoglossal, the portio dura, the abducens or sixth, the 
motor branch of the fifth, the fourth, and the third. The upper part 
of the spinal accessory arises from a nucleus situated in the lower part 
of the medulla oblongata, a little outside the central canal, and con- 
cealed by the posterior pyramid ; and it becomes superficial as the 
lowermost member of the eighth pair at the lateral aspect of the medulla 
below the level of the olivary body. The nucleus of the ninth, or hyp- 
oglossal nerve, commences below in front of the spinal canal, in con- 
tact with the spinal accessory nucleus, and extends for a short distance 
along the floor of the fourth ventricle in the neighborhood of the cala- 
mus scriptorius. Its superficial origin is between the olivary body and 
the anterior pyramid. The common nucleus of the portio dura of the 
seventh pair and abducens is situated just in front of the hypoglossal 
nucleus. The former nerve becomes superficial at the posterior margin 
of the pons, between the middle and inferior peduncles of the cerebel- 
lum ; the latter in the groove between the anterior pyramid and the 
pons. The nucleus of the motor-root of the fifth pair is situated within 
the fasciculus teres, a little above, in front of, and external to that of 
the portio dura ; the nerve becomes superficial by penetrating the lateral 
portion of the pons. The third and fourth pairs arise in common from 
a pair of nuclei, situated side by side in the floor of the iter. The 
fourth nerves encircle the iter in their course, and then winding round 
the outer side of the crura cerebri reach the base of the brain ; each 
third nerve penetrates the subjacent locus niger, and makes its appear- 
ance on the inner side of the crus. 



ANATOMY AND PHYSIOLOGY. 



857 



The sensory nerves, in their order from behind forwards, are the 
vagus and glosso-pharyngeal, the auditory, and the sensory portion of 
the fifth ; to which may be added the optic and the olfactory. The 
nucleus of the vagus, connected with that of the spinal accessory below, 
appears on the floor of the fourth ventricle, just above the calamus and 
external to the hypoglossal nucleus. Above, it appears to sink be- 
neath the auditory nucleus. The glosso-pharyngeal nucleus, which is 
partly continuous with that of the par vagum, but higher up, is wholly 
concealed by the auditory nucleus, with which it is in some measure 
blended. These two nerves become superficial along the posterior bor- 
der of the olive. The auditory nucleus is of large size; it involves the 
upward continuation of the gray matter of Rolando, and, in part, the 
posterior pyramid and restiform body. It occupies the floor of the 
ventricle external to the fasciculus teres, and its outer part turns back- 
wards with the restiform body to reach the cerebellum, some portion of 
it becoming connected with the dentate nucleus, some stretching across 
the roof of the ventricle to join its fellow. The nerve-fibres arising 
from this nucleus, taking various routes, combine to form the portio 
mollis, which has its superficial origin at the posterior margin of the 
pons, between the superior and middle cerebellar peduncles. The nu- 
cleus of the sensory portion of the fifth is, like the auditory, largely de- 
veloped out of the upward continuation of the gray tubercle of Rolando, 
and also from that of the root of the posterior horn. It is situated in 
advance of the nucleus of the portio mollis, with which indeed it is, to 
some extent, connected behind, and extending upwards to the fossa, 
where the fillet meets the anterior fibres of the pons, arches backwards 
with the rest of the continuation of the gray matter from the cord, 
towards the sides and roof of the anterior part of the fourth ventricle 
and of the adjoining part of the iter. The superficial origin of the 
nerve is to the anterior and outer part of the pons Varolii. The optic 
nerves interlace in the chiasm a, and thence each optic tract winds round 
the corresponding eras cerebri to reach the posterior portion of the 
optic thalamus, the corpora geniculata and the corpora quadrigeinina 
of the corresponding side, which therefore may be regarded as its nu- 
clei, or at all events as containing its nuclei; but, further, the optic 
tract, in its whole extent, is intimately connected structurally with the 
cms cerebri and the chiasma with the gray matter lining the third ven- 
tricle. The olfactory nerve is really, as comparative anatomy has long 
shown, a lobe of nervous substance. It is formed of gray and white 
matter, and contains, according to Meynert, a central ventricle continu- 
ous with those of the cerebrum ; its so-called roots are connected re- 
spectively with the anterior and posterior extremities of the gyrus for- 
nicatus, and some of the white fibres connected with it have been traced 
into the anterior commissure. It is an important fact that the fibres 
of the anterior commissure are connected with the occipital and tem- 
poral lobes only, and that hence the olfactory nerves, and it may be 
added, from their connection with the optic thalami and associated gan- 
glia, the optic nerves, are both intimately connected with that portion 
of the brain with which, through the intermediation of the same gan- 
glia, the rest of the sensory nerves are connected. 



858 DISEASES OF THE NERVOUS SYSTEM. 

Motor and Sensory Functions. — It will be convenient now to con- 
sider briefly, partly by way of recapitulation, some of those anatomico- 
physiological data in relation to the brain and other portions of the 
nervous system which have a special interest in connection with the 
pathology of these organs. The anterior portion of the surface of the 
brain (all that in front of the fissures of Rolando, together with the 
ascending parietal convolutions behind those fissures, and certain other 
convolutions connected therewith) appears on sufficiently good grounds 
to be regarded as the supreme organ of the cerebro-motor processes or 
impulses ; and, indeed, as has been already pointed out, pathological 
and experimental investigations have demonstrated that certain definite 
regions of this area are connected with certain special groups of com- 
bined movements. From all this extent of surface radiating fibres 
converge to certain parts at the base of the brain, namely, the caudate 
and lenticular nuclei of the corpora striata and the white matter (the 
internal capsules) which lies between these bodies and the optic thalami. 
Of these radiating fibres some pass without interruption through the 
internal capsules, while others enter the nuclei of the corpora striata. 
Below these nuclei the fibres passing uninterruptedly through the in- 
ternal capsules, together with others given off from the under surface 
of the corpora striata, form the crustaa of the crura cerebri, which con- 
tinued downwards through the pons Varolii, emerge from its posterior 
border in the form of the anterior pyramids of the medulla oblongata. 
Hitherto the fibres derived from each cerebral hemisphere have trav- 
elled downwards and backwards on the corresponding side of the. 
body ; at the lower part of the anterior pyramids, however, decussa- 
tion takes place, and the fibres of the anterior pyramid of one side are 
continued downwards, mainly along the anterior and lateral white col- 
umns of the opposite side of the cord. But, in addition to the corpora 
striata, with which bodies all the fibres passing from the cerebro-motor 
region of the brain have, in their passage downwards, a more or less 
intimate connection, there are, imbedded as it were in each lateral 
motor tract, a series of subordinate motor centres or nuclei, succeeding 
one another in close succession from the floor of the iter above to the 
termination of the cord below, each one of which gives origin to a 
motor nerve or to a certain number of fibres going to the constitution 
of a motor nerve. 

It follows generally from the above account that complex motor 
impulses, originating in the hemispheres of the brain, are conveyed 
along the radiating fibres to the corpora striata, through the agency of 
which bodies, resolved as it were into their simplest elements, they are 
transmitted to the several subordinate cerebral and spinal nuclei which 
immediately govern the movements of those muscles, which in combi- 
nation effect the intended result. It follows generally also that im- 
pulses originating in one cerebral hemisphere act through the corpus 
striatum of the same side upon the spinal nuclei of the opposite side 
of the body, and hence upon the muscles of the opposite side of the 
body. It must be added that the same holds good of those nerves 
whose origins are situated above the decussation of the pyramids. 
There are, however, certain exceptions to these statements, due doubt- 



I 

ANATOMY AND PHYSIOLOGY. 

! less to the fact of the intimate connection by means of commissural 
' fibres between the two hemispheres of the brain, and to the similar 
| connection which subsists between the corresponding motor nuclei of 
opposite sides along the motor tracts. Further, it must not be for- 
gotten that every subordinate motor centre has independent motor 
powers ; that, if the cerebrum be removed, or its functions in abey- 
ance, combined movements, to all appearance voluntary, may be ef- 
fected through the immediate agency of the corpus striatum, that if 
the spinal centres be cut off from their connection with the higher 
centres, these also are capable of inducing reflex movements, and that 
under various conditions of health and disease the independent action 
of these various subordinate centres is a fact of more or less impor- 
tance. 

The afferent or sensory nerves, which near their entrance into the 
spinal marrow are furnished with ganglia, penetrate into the posterior 
cornua, and thus become connected with that portion of gray matter 
lying behind the central canal which constitutes the sensory region of 
the spinal cord. This sensory region occupies the whole length of the 
cord, and at the medulla oblongata becomes split longitudinally from 
before backwards, both halves passing upwards, one on either side of 
the now superficial motor nuclei of the medulla oblongata, to form the 
tegmenta and to become connected with the optic thalami, corpora genic- 
ulata, and corpora quadrigemina, and thus with the nuclei of origin 
of the optic nerves. From these ganglia radiating fibres proceed 
mainly to the gray cortex of the posterior portions of the cerebrum or 
to the true sensorium. Thus it appears that the posterior part of the 
cerebral surface has some such relation with the sensory functions as 
the anterior has with the motor functions, and the optic thalami and 
ganglia behind it some such connection with the same system as the 
corpora striata have with the motorial. And further, it seems proba- 
ble (judging at all events by the analogies afforded by the organs of 
seeing and hearing) that complicated external impressions become ana- 
lyzed or disentangled, as it were, or reduced to their simplest elements 
by the organs which first receive them ; to become again blended into 
a whole, so to speak, in their onward progress to the sensorium. Both 
experiment and pathology have demonstrated conclusively that the 
sensory tracts decussate equally with the motor ; and that the cerebral 
hemisphere and optic thalamus of one side are in direct relation with 
the sensory tract and nerves of the opposite half of the medulla ob- 
longata and spinal cord. The decussation does not, however, take 
place in the pyramids or at any one spot ; but each sensory nerve im- 
mediately after its entry into the gray matter of the cord decussates 
with its fellow of the opposite side, and its fibres of communication 
with the optic thalamus continue thenceforward to pass upwards on 
the same side as that body. 

It appears to be certain that an important function of the cerebellum 
is to preside over the co-ordination of movements, and especially per- 
haps as suggested by Dr. Broadbent over those guided by vision and 
such as are volitional. Its relations with the motor and sensory tracts 
as they traverse the base of the cerebrum have already been considered, 



859 



860 DISEASES OF THE NERVOUS SYSTEM. 

and its connection with the posterior columns of the cord through the ; 
intervention of the restiform bodies pointed out. It is further estab- 
lished that the posterior columns of the cord are in no sense the con- 
ductors of ordinary sensory impressions, as from their position was j 
formerly supposed, but that they are mainly subservient to the co- 
ordinating functions. 

It is important to bear in mind that at the base of the brain, and 
especially in the situation of the pons Varolii and medulla oblongata, 
the sensory and motor tracts of both sides become to some extent in- 
termingled, that the nuclei of origin of many nerves of the highest in- 
terest and importance are crowded together into a very small area, and 
that hence disease affecting these parts is liable to be attended with 
complex, aggravated, and it may be added striking features; and that 
as regards the cord the sensory tracts are wholly imbedded in its in- 
terior, while all the white matter which forms its peripheral portion as I 
well as the anterior cornua belong to the motor system, and that hence 
the sensory columns are specially protected from the influence of 
pressure or other injurious influences operating from without. 

Sympathetic System. — The sympathetic system of nerves appears to 
have its supreme centre in the medulla oblongata; but it is intimately 
interwoven with the spinal system, and, as is well known, each spinal 
nerve receives branches from, and transmits branches to, a neighboring 
sympathetic ganglion. We need not consider the anatomical details of 
this system ; it is sufficient to point out that it presides over the i 
shortening and lengthening of the organic muscular fibres wheresoever 
situated, that it determines the dilatation and contraction of the blood- 
vessels, and therefore the amount of blood supplied to various parts, 
and in some degree the rapidity of its flow through them, and that it 
thus regulates to some extent the nutritive and other functions of the j 
different parts of the organism and their temperature. There is some 
reason also to believe that special branches are supplied to the secreting 
cells of some, if not of all of the glandular organs, and that hence a j 
direct influence is exerted by them over the physiological processes : 
which go on in these organs. 

Arteries of Brain. — The meningeal arteries, or those which are dis- 
tributed to the dura mater, are derived mainly from branches of the 
external carotids. A minute branch is, how T ever, furnished by each 
vertebral artery immediately after its entrance into the skull. These 
have no connection with the arteries which supply the brain and its | 
vascular membrane, the pia mater. 

The proper arteries of the brain are derived from the common caro- 
tids and the vertebrals, which, after entering the skull and giving off 
certain branches, to some of which we shall presently again refer, form 
between them that remarkable anastomosis known as the circle of 
Willis. Each internal carotid artery having first given off the 
ophthalmic and then the posterior communicating artery, divides into 
two branches, namely, the anterior and the middle cerebral. The 
anterior cerebral, which is the smaller of the two, anastomoses after a 
short course with its fellow by the anterior communicating artery. Its 
trunk then turns round the anterior edge of the corpus callosum, and 



ANATOMY AND PHYSIOLOGY. 861 

runs backwards along the upper surface of that body. It divides into 
three principal branches, of which the first is distributed superficially 
to the orbital convolutions below, and to a small portion of the inner 
aspect of the hemisphere in the neighborhood ; the second is distributed 
to the first and to the greater part of the second frontal convolution, 
and to the upper extremity of the ascending frontal, as well as to all 
that part of the inner aspect of the hemisphere which lies between the 
; area of distribution of the first branch and the ascending limb of the 
fronto-parietal fissure, including the anterior two-thirds of the corpus 
callosum; and the third branch is distributed to that area of the inner 
surface of the hemisphere which lies between the ascending limb of the 
fronto-parietal and the parieto-occipital fissure, and to the posterior 
part of the corpus callosum. The middle cerebral artery divides in the 
fissure of Sylvius into four branches, which, radiating in conformity 
with the convolutions of the island of Reil, and supplying them with 
vessels, emerge on to the outer surface of the brain, and are thus dis- 
tributed : The anterior or first branch ramifies over the third frontal 
convolution exclusively; the second is distributed to a portion of the 
second frontal convolution and to almost the whole of the ascending 
frontal ; the third supplies mainly the ascending parietal and superior 
parietal convolutions, the posterior and lower limit of its distribution 
being indicated partly by the interparietal fissure, and partly by . a 
horizontal line drawn from this to a point on the upper margin of the 
hemisphere midway between the parieto-frontal and parieto-occipital 
fissures ; the fourth or posterior branch is distributed to the first and 
second temporal convolutions, and to the gyrus angularis, its posterior 
limit being determined by a line drawn from the posterior extremity 
of the second temporal sulcus to the parieto-occipital. The posterior 
cerebral arteries result from the division of the basilar; each sends 
branches into the brain-substance at the locus perforatus posticus, is 
then joined by the posterior communicating artery of the same side, 
and finally gives off three principal branches, which are distributed to 
all those parts of the cerebral surface which have been hitherto unac- 
counted for: the anterior to the uncinate convolution; the middle to 
the third temporal and the fusiform or lateral occipito-temporal convo- 
lutions, and to the hinder part of the gyrus fornicatus ; and the posterior 
to the median occipito-temporal convolution, to the cuneus, and to the 
occipital lobe. 

The distribution of the arteries to the ganglia at the base of the 
brain is not less important than that upon the surface of the organ. 
All three pairs of cerebral arteries take for the most part a greater or 
smaller share in supplying these bodies. The anterior cerebral gives 
small branches to the anterior extremity of the corpus striatum only, 
and not unfrequently none at all. The middle cerebral, on the other 
hand, has a comparatively wide and a very important distribution. It 
gives off many branches of somewhat large size, which, entering at the 
locus perforatus anticus at right angles, or nearly so, to the trunk, 
supply the whole of the lenticular nucleus of the corpus striatum, the 
whole or greater part of the caudate nucleus, the internal capsule, and 
the anterior and outer part of the optic thalamus. They may be divided 



862 



DISEASES OP THE NERVOUS SYSTEM. 



into two groups : an internal group, consisting of comparatively small 
vessels, which are distributed to the internal portions of the lenticular 
nucleus, and to the adjoining portions of the internal capsule ; and an 
outer group of vessels of considerably larger size, which course mainly 
over the outer aspect of the lenticular nucleus, and supply the outer 
part of that body, and also, according to their position, the caudate 
nucleus or the optic thalamus. One of these branches is called by 
Charcot " the artery of cerebral haemorrhage." It is pre-eminently 
large, and, after penetrating the outer part of the lenticular nucleus 
and traversing the internal capsule, enters the substance of the caudate 
nucleus, and passes from behind forwards in it to its most anterior 
part. The posterior cerebral arteries give branches to the choroid 
plexuses and ventricular walls, and supply also the tegmentum, the 
corpora quadrigemina, and the posterior and inner parts of the optic 
thalami. The branches which they give to the last-named bodies may 
be divided into internal and external. The former supply the inner 
aspects of the thalami, and their rupture is apt to be followed by the 
profuse escape of blood into the ventricular cavities ; the latter supply 
the outer parts of the thalami, and since before they enter them they 
pass through the cerebral peduncles, their rupture is apt to be attended 
with effusion of blood into the substance of these latter bodies. 

• The vertebral arteries unite to form the basilar, which divides 
again in front into the two posterior cerebrals. The vertebrals, be- 
sides supplying meningeal and spinal branches, give off on either side 
a posterior inferior cerebellar artery, which is distributed to the pos- 
terior portion of the lower aspect of the cerebellum and to the choroid 
plexuses of the fourth ventricle. The basilar, in addition to sending a 
branch to each internal ear and other branches to the substance of the 
pons, gives off also a right and a left anterior inferior cerebellar artery 
to the anterior part of the under surface of the cerebellum, and a right 
and a left superior cerebellar artery, which are distributed over the 
whole of the superior surface, of the cerebellum, and supply the valve 
of Vieussens and partly the velum interpositum. 

It is necessary to bear in mind — for, indeed, it is this point which 
makes an accurate acquaintance with the details of the cerebral circu- 
lation important — that, save at the circle of Willis, little or no com- 
munication takes place between the branches of the cerebral arteries, 
even down to their finest ramifications, excepting by means of capillary 
vessels ; and that hence, if any artery become obstructed, the region to 
which that artery leads almost necessarily suffers in its whole extent. 
Thus, if the middle cerebral be blocked, the nutrition of the whole 
region to which it is distributed becomes impaired ; if one of its 
primary branches be obstructed the limitation of morbid change is 
equally definite ; and if a secondary or even smaller vessel be alone 
involved, secondary changes will be limited to correspondingly minute 
districts. It is important, further, in reference to this point, to know 
that the arteries on the surface of the convolutions give off long and 
short branches, which are quite distinct from one another; and of 
which the short are distributed to the cortical gray matter, the long 
enter the white substance, and are limited in their distribution to it. 



PATHOLOGY. 



863 



It is scarcely necessary to add that the ultimate arteries supplying the 
ganglia are equally distinct from both. 

It is a matter of no slight practical importance that the ophthalmic 
artery arises from the same trunk as that which gives off the anterior 
and middle cerebral arteries ; and that the ophthalmic artery supplies 
not only the eyeball itself, but the contents of the orbit, including the 
lachrymal gland, and gives off branches to the eyelids and contiguous 

! portions of the forehead and nose, and to the ethmoidal cells. The 

1 arteries of the internal ear again are mainly derived from one of the 

| intracranial arteries, namely, the basilar. 

Veins of Brain. — The veins distributed over the surface of the cere- 

| brum and cerebellum open into the several sinuses to which they are 
respectively contiguous ; those situated within the lateral ventricles 

| converge to the venae Galeni, by means of which they empty them- 
selves into the straight sinus. It is needless to enumerate or trace the 
several sinuses. There are, however, two or three points in connection 
with the venous circulation of the brain, which are important. These 
are : first, that the cerebral and cerebellar veins all converge, directly or 
indirectly, to the lateral sinuses, and that hence all or nearly all the 
blood from these parts is returned by the internal jugular veins; sec- 
ond, that the ophthalmic vein, which has almost exactly the same dis- 
tribution as the ophthalmic artery, empties itself into the cavernous 
sinus on the one hand, and anastomoses with the branches of the facial 
and other veins towards its peripheral extremity ; and, third, that the 
longitudinal sinus communicates with the veins on the exterior of the 
skull through the parietal foramen, and the lateral sinuses with those 
of the head and neck through the mastoid foramina. 

Pathology. 

Most diseases of the nervous system may affect any part of that sys- 
tem ; and hence, although in many cases evoking symptoms indicative 
of their specific nature, they tend also to evoke symptoms referable to 
the particular part of the nervous organism which they involve, and to 
the extent or mode in which they involve them. As regards the last 
point, it is obvious that here as elsewhere the functions of parts may 
be impaired, exalted, or perverted. And as regards the part affected, it 
is clear that disease may involve some portion of the motor tract, or some 
portion of the co-ordinating tract, or some portion of the sensory tract; 
and that it may be seated either in the peripheral nerves, or in the cord, 
or in the intracranial centres ; and that the symptoms will vary ac- 
cordingly. Further, if the supreme centres be involved, there will be 
not only pathological sensory or motor phenomena, but also phenomena 
referable to the intellectual and emotional functions. We proceed to 
discuss some of the more important phenomena which are dependent on 
the situation of the part affected, and on the degree or mode of its in- 
volvement. 



864 



DISEASES OF THE NERVOUS SYSTEM. 



! 



1. Motor Paralysis. Paresis. 

By the term " paralysis " is meant the more or less complete loss of 
that power which the higher centres should exert over the movements 
of the muscles. The term "paresis" is often used of the slighter forms 
of this condition. Paralysis. of the voluntary muscles, to which alone 
we now confine our attention, may vary from the slightest degree of 
impairment of voluntary power over them to that condition in which 
every trace of such power has disappeared, and the part affected is ab- 
solutely motionless and incapable of motion. The quality also, of this 
paralysis varies in different cases. In some, as in general paralysis of 
the insane and disseminated sclerosis, the enfeebled muscles become 
tremulous under the attempt to use them; more commonly, as in most 
cases of ordinary hemiplegia, their movements are slow, and weak, and 
halting, but uniform. In some cases the paralyzed muscles retain their 
normal bulk, in others they waste ; in some they are flaccid, in some 
they preserve their natural tonic condition, while in others they are 
rigid and perhaps contracted ; in some cases, again, they have more or 
less completely lost their electric contractility, in others they retain 
their contractility, and occasionally this quality becomes exalted ; and, 
lastly, in different cases the electro-sensibility of the affected muscles 
becomes either impaired or exalted, or remains unaffected. 

Cerebral Paralysis. — 1. General paralysis rarely occurs except in 
association with insanity, and is then due, as might be supposed, to 
some general impairment of the surface of the brain. It is for the 
most part slight in degree, and indicated by feebleness, not only of the 
muscles of the limbs, but of those of the trunk, head, and neck, and 
those of expression, mastication, and deglutition. Further, as has been 
already pointed out, the muscles are usually slightly tremulous when 
put into action. 

2. Hemiplegia. — Any morbid condition affecting any part of either 
of the hemispheres of the cerebrum is apt to be attended with more 
or less general paralysis of the opposite side of the body. Neverthe- 
less it is an important fact that disease, and even extensive disease, may 
exist there, and yet no obvious paralysis result. Assuming paralysis to 
exist, it must not be forgotten, in reference to the determination of its 
exact seat, that damage to the posterior part of the left third frontal 
convolution and its vicinity involves, as a rule, more or less impairment 
of the faculty of speech, and that there are certain other parts of the 
cerebral surface which experimental research shows to have (at least in 
the lower animals) some special relation with the movements of cer- 
tain groups of muscles. Hemiplegia, however, commonly results from 
disease involving one of the corpora striata and the white substance in 
its immediate neighborhood. It is then usually developed in its typi- 
cal form. It involves the opposite side of the body, but not all parts 
of it equally. The cerebral motor nerves are affected comparatively 
little, and their involvement increases as a rule from before backwards. 
Thus the movements effected by the third, fourth, and sixth nerves are 



I 



BULBAR PARALYSIS. 



865 



I rarely if ever impaired, so that the motions of the eyeball on the af- 
fected side continue, for the most part, perfect. Again, the motor- root 
of the fifth nerve suffers, as a rule, but little. The portio dura, on the 
other hand, is generally distinctly involved, but only slightly and un- 
equally. Thus the face is usually more or less blank on the affected 
side, the muscular wrinkles more or less effaced, the mouth drawn to 

| the opposite side, the eye a little more open than its fellow, and wink- 
ing a little less rapidly performed. Nevertheless the eye can generally 
be perfectly closed, and some power of movement remains in the whole 
of the side of the face, but more especially in its upper half. The hy- 
poglossal is almost invariably markedly involved, and the tongue con- 
sequently is protruded towards the paralyzed side of the body . The motor 
fibres of the par vagum, and it may be added those of the spinal nerves 
going to the muscles of the head and neck and trunk, suffer but little ; 
and hence the patient as a rule has no difficulty in deglutition, or in 
phonation, in maintaining the due position of his head, in respiration, 
or in the acts needing the employment of the muscles of the abdomen 
or back. On the other hand, the muscles of the arm and leg are al- 
ways chiefly affected. If the case be severe they are alike motionless; 
but it is a curious fact that if there be a difference between them it is 
that the leg retains a greater degree of motor power than the arm, that 
it is the last to be involved, the first to recover. In explanation of the 
different degrees in which the motor nerves on the hemiplegic side 
suffer it may, of course, be assumed that, owing to some particular ana- 
tomical arrangement, certain strands of fibres passing to or by the cor- 
pus striatum lie, as a rule, beyond the influence of the morbid condition 
on which hemiplegia usually depends. It may also, and with much more 
probability, be assumed (as has been done by Dr. Broadbent) that the 
nuclei of those nerves which thus seem to escape are more intimately 
connected with their fellows than are the nuclei of other nerves, and 
are hence influenced in a greater degree than they by the motor im- 
pulses which descend from the opposite side of the brain. And in con- 
firmation of this view it may be pointed out that those which thus es- 
cape are, as a rule, such as act in co-ordination, and whose combined 
actions we cannot voluntarily restrain. 

Bulbar Paralysis. — When paralysis arises from disease situated 
within the medulla oblongata or pons Varolii, it is obvious, from the 
abundance and close proximity of important nerve-nuclei in these 
organs, and from the fact that the sensory and motor strands from both 
cerebral hemispheres here meet and blend, that such one-sided limita- 
tion of paralysis as occurs in hemiplegia is scarcely likely to be present, 
and that if there be general paralysis it must differ largely in its de- 
tails and in its danger to life from that which has been before adverted 
to. It is in such cases that what is called cross paralysis is sometimes 
met with— paralysis, that is to say, of one side of the body and of the 
opposite side of the face. It is in such cases, again, that we sometimes 
find paralysis of both arms and legs, or of one arm and both legs, or 
the converse. And, moreover, it frequently happens, for obvious 
reasons, that there is more or less paralysis of the muscles of one or 

55 



866 DISEASES OF THE NERVOUS SYSTEM. 

other or both eyeballs, or of one or other or both facial nerves; or that 
there is difficulty of articulation, or phonation, of mastication, deglu- 
tition, or respiration, or of control over the rectum or bladder ; or that 
a greater or less number of these paralyses occur in combination. It 
must be recollected, in reference to these cases, and equally in reference 
to diseases involving the under surface of the brain, that, together with 
the opposite or hemiplegic paralysis due to involvement of nerve-tissue 
above the nerve-nuclei, we are always apt to have paralysis, generally 
of the same side, due to the direct implication of nerve-nuclei or of 
nerves after their emergence from their nuclei. It is by this circum- 
stance that cross paralysis is to be explained. The great danger to life 
which, as is well known, attends disease of the parts now under consid- 
eration is due mainly to the paralysis of the organs of deglutition, res- 
piration, or circulation, which is almost invariably present in a greater 
or less degree. 

Spinal Paralysis. Paraplegia. — When paralysis is due to disease of 
the spinal cord, it generally goes by the name of paraplegia, and is 
specially characterized by the fact that the paralysis involves only the 
muscles supplied by those nerves which are given off from the cord at 
and below the seat of disease. The symptoms will of course vary, both 
with the situation and with the extent of the lesion. Thus if it involve 
the whole thickness of the cord high up in the neck above the origin 
of the phrenic nerves, there will be complete motor paralysis of all 
parts seated below — of the arms and legs, as also of the diaphragm and 
other respiratory muscles. If it be situated at or above the cervical 
enlargement, the movements of the diaphragm will be unaffected, but 
the arms and legs will be paralyzed as in the former case. If the 
dorsal region of the spine suffer, the arms will necessarily escape, and 
the paralysis will be limited to the lower extremities and to just so 
much of the lower part of the trunk as is supplied by nerves given off 
below the seat of mischief. In all such cases there is more or less in- • 
terference with the functions of micturition and defecation. If the ; 
disease be seated high up, as in the cervical or upper part of the dorsal 
region, there is usually difficulty in the act of micturition, owing to J 
spasm of the sphincters ; if, on the other hand, the disease be situated 
in the lower dorsal or lumbar region, the sphincters are paralyzed, and 
the urine consequently escapes spontaneously. The bowels are usually 
constipated, and defecation is performed involuntarily. It need scarcely 
be added that in complete paralysis sensation as well as motion is an- 
nulled. 

But paralysis below the seat of lesion is not necessarily complete. 
In many cases of paralysis due to pressure or disease of the surface of 
the cord, or of the structures which surround it, sensation remains per- 
fect, or nearly so, while motorial power is wholly lost. In many cases, 
again, the paralysis, though involving all parts below, involves them 
only to the extent of impairing their power of motion in a greater or 
less degree. And, further, many cases are met with in which the dis- 
ease implicates certain defined tracts only of the cord. The conse- 
quences are then often very remarkable. If one lateral half only be 



PARAPLEGIA. 



867 



the seat of disease, and this be affected in its whole horizontal area, but 
to a limited extent vertically, complete paralysis necessarily involves 
all the motor nerves given off from the cord on the same side as the 
lesion, but below it, in consequence of the lesion having cut off all 
direct connection between them and the brain above. But, inasmuch 
as the decussation of the sensory nerves takes place in the cord itself 
immediately after their entry into the cord, it follows that the sensory 
nerves associated with the paralyzed regions remain unaffected, while 
those of the corresponding regions of the opposite side of the body share 
the fate of the motor nerves of the diseased side. Hence arises paraly- 
sis with retention of normal sensation on one side ; anaesthesia, with 
perfect power of motion, on the other side ; and in some cases a more 
or less distinct line of anaesthesia forming, on the side of lesion, the 
i uppermost limit of the region of motor paralysis. Perfect unilateral 
i limitation of disease is of course not very common ; it is more usual to 
find one side involved in a segment only of its horizontal area, or both 
sides involved more or less, and in unequal degrees; and it need scarcely 
! be said that under such circumstances the paralytic phenomena which 
result are less typically and more irregularly distributed. 

It is a curious fact, which will hereafter be more fully considered, 
that certain forms of disease have a remarkable tendency to involve 
particular regions or strands of the cord, and to be limited to them. 
The regions to which particular reference is here made are the posterior 
columns, the lateral columns, and the groups of large nuclei (motor 
nuclei) in the anterior cornua. When disease affects the posterior 
columns only, or, as Charcot points out, the outer bands of these 
columns, which abut directly on the inner and posterior aspects of the 
posterior cornua and the roots of the sensory nerves, the condition 
known as locomotor ataxy, in other w T ords, the loss of co-ordinating 
power, and not the ordinary form of motor paralysis, involves the 
voluntary muscles of all those parts which are below the seat of dis- 
ease. In a large proportion of cases the legs alone thus suffer, but the 
arms and even parts above the arms are all liable to become implicated. 
Incoordination is shown, partly by loss of the muscular sense, in virtue 
of which the patient is unable to judge of the amount of force needed 
to accomplish definite results, and unable therefore (especially if his 
eyes be closed) to determine the position of his affected limbs in rela- 
tion to other parts of his person or to surrounding objects ; and partly 
by want of control over his voluntary movements, which are conse- 
quently more or less violent than necessary, and involve a larger or 
smaller number of muscles than are suitable for their execution. 
There is not, however, any necessary loss of muscular strength, and 
the affected limbs sometimes retain extraordinary power. When the 
lateral columns only are the seat of disease, or more particularly the 
white matter which lies behind the horizontal line drawn laterally 
through the median canal, motor paralysis ensues in all those parts 
which are situated below the seat of lesion ; but under these circum- 
stances, according to Charcot, the muscles of the affected limbs tend to 
become, not only paralyzed, but at first tremulous and ultimately more 
or less rigid and contracted. If the groups of large cells in the anterior 



868 



DISEASES OF THE NERVOUS SYSTEM. 



I 



cornua are diseased, then only the nerves which take their origin in 
them, and those muscles which these nerves supply, suffer : the muscles 
become paralyzed, and in a large number of cases speedily lose their 
electro-contractility, and waste. 

Nerve Paralysis. — In the foregoing account we have considered more 
especially those forms of paralysis which are due to disease occurring 
above the nuclei of origin of the paralyzed nerves. We have, however, 
referred here and there to the fact that paralysis may be caused by dis- 
ease involving these nuclei, or by disease implicating the nerves after 
their emergence from them. We have, indeed, in considering paralysis 
due to disease originating within the brain or cord, been almost com- 
pelled to advert to the fact that, when the disease occupies certain 
situations, more especially the pons, medulla oblongata, base of the 
brain, and spinal cord, the paralysis which so commonly ensues is 
necessarily apt to be compounded of paralysis due to the cutting off 
of the connection between nerve-nuclei and the higher centres, and of 
that dependent on direct implication of nerve-nuclei or of the nerves 
beyond them. Paralysis due to the destruction of a nerve or of its 
nucleus of origin, is necessarily of very limited distribution ; it affects 
a single muscle or a group of muscles ; the external rectus of one eye, 
or the superior oblique, or the other muscles of the eyeball together 
with the levator palpebra?, or the muscles of expression of one side of 
the face, or certain muscles of the head and neck, or trunk, or extremi- 
ties. In the second place it tends soon to become absolute. It is not, 
of course, denied that other varieties of paralysis are also not unfre- 
quently absolute ; but, as we have pointed out, in ordinary well-marked 
hemiplegia, certain nerves appear to escape implication, and certain 
others, such as the portio dura, become involved only to a slight ex- 
tent. In paralysis of the portio dura, however, due to disease involving 
the nerve directly, the paralysis of the muscles which it supplies is 
usually general and complete. In the third place the paralyzed muscles 
often very rapidly lose the power of responding to the electrical stimulus, 
and then also soon grow flaccid and waste. 

Condition of Muscles in Motor Paralysis. 1. Tone. — In some cases 
of paralysis the muscles retain their normal tonicity; in some they are 
limp and flaccid ; in some they become rigid and contracted. The 
normal tonicity is preserved in a large number of cases of both cerebral 
and spinal paralysis. Limpness of muscles not unfrequently attends 
those cases of paralysis of the same centres in which the affection to 
which the paralysis is due is sudden in its onset and extensive; it 
generally also becomes soon developed in those muscles whose nerve- 
nuclei are directly inrplicated, or in those whose connection with these 
nuclei is interrupted. Rigidity or contraction of the muscles in cere- 
bral or spinal disease is often the consequence of some irritation, in- 
flammatory or other, going on at the seat of disease. It is then to be 
regarded as an acute condition, and generally comes on early. But 
rigidity, with more or less contraction, is apt to ensue gradually in 
cases of old paralysis; sometimes, in the case of atrophied muscles, 
from their gradual and slow longitudinal contraction, more frequently, 



I 



CONDITION OF MUSCLES IN PARALYSIS. 



869 



perhaps, in consequence of secondary degenerative changes going on in 
the lateral columns of the cord. 

2. Contractility and Irritability. — The contractility of muscles under 
the influence of the galvanic stimulus remains unimpaired in many cases 
of paralysis. In some cases, however, it becomes exalted, in some 
diminished, or annulled. Contractility is for the most part retained 
both in cerebral and ordinary spinal paralysis ; but in both, and more 
especially in the latter, it is not unfrequently exalted, so that the para- 
lyzed muscles are more readily thrown into contraction by a weak 
current than are the muscles which are still healthy. Loss of electric 
contractility usually takes place to some extent in the muscles of para- 
lyzed limbs which have been long disused, in consequence simply of 
their disuse; and when atrophic or degenerative changes are going on 
in muscles thpir contractility is necessarily impaired at least propor- 
tionately to the amount of injury or destruction that has taken place. 
The most remarkable instances, however, of such loss are those in 
which the paralysis is due to disease involving either the nerve-nuclei 
or the nerves connected with the affected muscles. In some of these 
cases the loss of electric contractility is marked and rapid, and not un- 
frequently it becomes totally abolished in the course of from five to ten 
days. In employing galvanism for the purpose of ascertaining the 
condition of muscles as to contractility (and it may be added for the 
purposes of treatment also), it is well to point out that we may avail 
ourselves either of Faradization or of the direct galvanic current. In 
the former case the currents are of momentary duration but of high 
tension, and alternately in opposite directions ; in the latter they are 
continuous in one direction only, and their tension is comparatively 
low. Faradization affects healthy muscles powerfully; and in a large 
proportion of cases it acts equally well on paralyzed muscles; and, 
indeed, the remarks above made upon the effects of galvanism on the 
muscles relate exclusively to Faradization. It is important, however, 
to bear in mind that the direct galvanic current, slowly interrupted, 
acts far more powerfully on many paralyzed muscles than on healthy 
muscles; and that even a feeble current will often readily evoke con- 
tractions in those which have become totally irresponsive to Faradiza- 
tion. 

3. Electro- Sensibility. — This condition (provided complete anaesthesia 
do not attend the muscular paralysis) is generally augmented with 
augmentation of muscular contractility, and diminished with the dimi- 
nution of that property. But occasionally, as for example in hysteria, 
contractility remains when muscular sensibility has disappeared ; while, 
on the other hand, it now and then happens that sensibility continues 
after the muscles have almost entirely ceased to contract. 

4. Nutrition. — In a considerable number of cases paralyzed muscles 
retain their bulk and texture, or at most become a little impaired in 
these respects, as even non-paralyzed muscles are apt to do, from mere 
disuse, and hence remain in a condition to take on active duty so soon 
as the cause of paralysis disappears. This, indeed, is generally the 
case when the cause of paralysis is situated above the nuclei of origin 
of the paralyzed nerves. In these cases, also, the muscles generally 



870 



DISEASES OF THE NERVOUS SYSTEM. 



retain their tone and electro-contractility little or not at all impaired, : 
and may remain thus for many years. When, however, the motor 
nuclei or nerves emanating from them are the seat of disease, rapid 
muscular emaciation usually takes place concurrently with loss of 
electro-contractility. To this subject we shall subsequently recur. 

5. Reflex Action. — Involuntary movement of paralyzed muscles, in 
obedience to reflex irritation, is a phenomenon of common occurrence. 
The most striking forms of reflex movement occur in cases of spinal 
paralysis, in which some circumscribed lesion cuts off all nervous con- 
nection between the brain and paralyzed limbs, leaving the portion of 
the cord with which these are connected in a healthy condition. In 
these cases, sometimes under the influences of defecation or micturition, 
sometimes from the irritation of bed-clothes, but more strikingly from 
touching or tickling the soles, the limbs may be made to execute vio- 
lent and repeated movements. When one sole is irritated the corre- 
sponding limb may be made by successive efforts to become powerfully 
flexed at the hip, knee, and ankle-joints, while the toes are widely sep- 
arated and extended. In most cases these reflex movements are limited 
to the irritated member; but in some instances both limbs become 
involved, and occasionally the muscular contractions are still more 
widely distributed. Similar reflex phenomena may generally be ex- 
cited in the paralyzed limbs, more especially the leg, of hemiplegic 
patients. It is obvious that reflex phenomena can only arise in those 
cases in which the connection between the paralyzed muscles and the 
nerve-centres of the cord are maintained ; and that hence they can 
never be present in cases of paralysis due to the destruction of nerves 
or of nerve-nuclei. A phenomenon referable to the same class is 
sometimes observed in the paralyzed muscles of patients suffering from 
cerebral paralysis, namely, the sudden movement of a paralyzed limb 
or of certain groups of muscles under the influence of emotional excite- 
ment. 

2. Ancesthesia. 

Anaesthesia, or impairment or loss of sensation, may, like paralysis, 1 
exist in various degrees, and occupy various regions of the body. It 
may be limited to the skin or to the muscles, or may involve the whole 
thickness of the part affected. The last variety is the most common. 
In its slighter degrees it is often attended with more or less tingling, 
pricking, formication, or sense of numbness, and the affected part, in 
relation to things with which it is brought into contact, feels to the 
sufferer as if protected or covered by some thick, soft texture. If his 
hands be the seat of anaesthesia, they seem as if clothed with thick 
gloves, if his feet, as if he were walking on cotton wool or other soft, . 
yielding material. In extreme cases the skin and subjacent parts are 
wholly insensible to external impressions, and admit of being pricked, 
cut, burnt, or otherwise injured, without the knowledge of the patient. 
In most cases abeyance of ordinary tactile sensibility is attended with 
similar abeyance of the capacity for distinguishing painful impressions, 
and heat and cold ; but this is not always the case, for now and then 
the capability of recognizing these latter impressions appears to sur- 



ANAESTHESIA. 871 

vive in some degree when the capability of distinguishing the former 
is wholly lost — a fact which has led some physiologists to believe that 
these different forms of sensation travel to the sensorium by different 
routes. Muscular sensibility is sometimes impaired or lost in cases of 
paralysis, while the cutaneous sensibility remains unaffected, and occa- 
sionally, in hysterical cases, muscular insensibility, with or without 
cutaneous anesthesia, goes along with unimpaired muscular contrac- 
tility. 

Anesthesia, equally with motor paralysis, may depend on disease in 
the brain, disease in the medulla, or other parts at the base of the brain, 
disease in the cord, or disease involving nerves. 

Cerebral Ancesthesia. — 1. General impairment of sensibility may attend 
the general paralytic condition which is associated with a special form 
of insanity. 

2. Hemiancesthesicc may arise, like hemiplegia, from disease of one 
of the cerebral hemispheres, or the ganglia or cms immediately con- 
nected with it. It is, however, of much less common occurrence than 
hemiparalysis, and rarely occurs independently of it. Theory, and to 
some extent perhaps, observation, would lead us to believe that disease 
affecting the posterior portions of the cerebral surface would be likely 
to be attended with unilateral or more or less localized anesthesia of 
the opposite side of the body. Hemianesthesia is, however, most 
commonly the consequence of disease involving the optic thalamus and 
white substance in its immediate vicinity, or the subjacent tegumentum. 
Hemianesthesia is in some cases absolute — the patient feels nothing, 
but more frequently it is incomplete — the patient feels generally, in 
some degree, or he retains more or less sensation in certain parts, more 
especially the palm or sole, or both, and certain parts of the leg or fore- 
arm ; or, as occasionally happens, the affected side is irregularly studded 
with more or less completely anesthetic patches. 

Bulbar Ancesthesia. — When disease involves the pons or medulla 
oblongata, some degree of anesthesia is very apt to be associated with 
motor paralysis, and like it, to be of irregular distribution. Of course 
all the sensory nerves which take their origin in these parts are, like 
the motor nerves, liable to be implicated. 

Spinal Anaesthesia. — Anesthesia from spinal disease, like that from 
cerebral disease, is far less common than the corresponding paralytic 
affection, and is rarely met with apart from it. There are several 
reasons for this : the sensory tracts of the cord are situated solely in 
• the posterior cornua, and the rest of the gray matter behind the central 
canal, so that they are apt to escape pressure and the other consequences 
of disease occupying the periphery of the cord or the surrounding tis- 
sues ; moreover, it seems to be proved by experiment, that a narrow 
thread of gray matter is sufficient to maintain an effective connection 
between the sensory tract below and that above. Disease limited to 
the central region of the cord, or rather to its posterior part, might 
conceivably induce anesthesia without paralysis. We have previously 



872 



DISEASES OF THE NERVOUS SYSTEM. 



pointed out the important fact that disease of one lateral half of the 
spinal cord, interrupting the longitudinal continuity of the fibres, causes 
anaesthesia of the opposite side of the body. 

Nerve Anaesthesia. — Local anaesthesia, like local paralysis, may arise 
from disease affecting either a sensory nerve or its nucleus, and thus 
necessarily occupies the same side of the body as that on which the 
lesion exists. Such anaesthesiae are not unfrequent in the area of dis- 
tribution of the fifth pair or of some of its branches, or in that of one 
or other of the spinal nerves. The anaesthesia which forms the upper 
boundary of the paralyzed region in cases of unilateral injury or dis- 
ease of the cord is a typical example of this condition. 

There are yet one or two points connected with anaesthesia which 
claim attention. The first of these is the fact that persons suffering 
from anaesthesia generally experience subjective sensations referable to 
the anaesthetic regions, and not unfrequently complain of neuralgic and 
other pains in them; the second is the phenomenon that sometimes, 
when sensation is greatly impaired, the patient does not take cogni- 
zance of impressions made on the affected part until after the lapse of 
a few seconds, or it may be as much as half a minute— the impression 
appears to be delayed in its transmission to the sensorium ; the third 
is the fact that, under similar circumstances, such patients often have a 
peculiar difficulty in distinguishing between the characters of different 
impressions; the last to which we shall refer is the circumstance that 
iuasmuch as it is through the sensory or afferent nerves that reflex 
motor phenomena are excited, it is obvious that, if the disease causing 
anaesthesia exist in the course of the nerve or in its nucleus, no irri- 
tation of its extremity can evoke reflex action, while if it be due to 
spinal disease, the probability is that irritation of the extremities of 
the anaesthetic nerves given off below the seat of disease will evoke 
muscular action in the corresponding muscles. Similar phenomena 
to the last, but of a more complicated character and of a higher order, 
seem not unfrequently to be produced through the agency of the 
nerves of sight and hearing. 

3. Convulsions. Spasms. 

In speaking of paralysis, we have referred to the facts that associated 
with this state it is not uncommon to observe tremulousness of muscles 
arising especially during voluntary efforts, and that paralyzed muscles 
occasionally become rigid and contracted. It may be added that con- 
vulsive movements of various kinds are not unfrequently associated with . 
paralysis. They more frequently, however, occur independently of it. 

Convulsions may affect single muscles or portions of muscles, groups 
of muscles, a limb, the head and neck, one half of the body, or the 
whole of it. They may be intermittent or continuous, and may vary 
in intensity from a scarcely perceptible flickering of the muscular 
fibres, to contractions of such violence and strength that the muscles 



i 



CONVULSIONS 



— SPASMS. 



873 



become ruptured. Intermittent contractions are termed clonic, persis- 

j tent contractions tonic. 

The slighter forms of convulsions are exemplified in the tremulous, 

j more or less rhythmical, movements which are observed under many 

I various conditions, and generally cease during sleep. Some of these 
attend efforts at voluntary movement only, and are then usually re- 
garded rather as evidence of debility than as convulsions in the true 
sense of the term, on the ground that they depend on the intermittent 
transmission of voluntary impulses only. In true convulsions there is 

I a similar intermittent transmission, but the force is exerted indepen- 
dently of and beyond the will. This distinction is useful to be borne 
in mind, but it is one that is not always available in practice, if indeed 
the two conditions do not frequently run the one into the other. 
Among the convulsions which on the above view should be referred to 

I debility are the fibrillar tremblings of the lips and tongue of patients 
suffering from general paralysis during their attempts to speak, and 

, the irregularly rhythmical movements of the limbs which not un- 
frequently attend the voluntary efforts of those laboring under dis- 

; seminated sclerosis of the nerve-centres; among those which are truly 
convulsive may be enumerated that flickering of the orbicularis pal- 
pebrarum which is known by personal experience to all, the general 
tremulousness which attends exposure to cold and febrile rigors, the 
subsultus tendinum of patients in the typhoid condition, the more or 
less general rhythmical tremors of paralysis agitans and chronic mer- 

! curial poisoning, and the tremors which occasionally attack the lower 
extremities of paraplegic patients. 

Another form of convulsion is that to which the term choreic may 
be applied, and of which chorea furnishes the most typical example. 
In this, as in the former series, the movements cease during sleep, and 
as in the paralytic form of trembling are greatly aggravated during 
voluntary efforts and under mental excitement. Choreic movements 
are characterized mainly by their abruptness and irregularity, and by 
the fact that when they are engrafted on any voluntary movement 
they interrupt its progress by a series of grotesque contortions and di- 
versions which are not then necessarily limited to the limb or organ 
which is making the effort. Choreic movements are not unfrequently 
hemiplegic or limited even to a limb. Related in some degree to 
chorea are the grimaces and other tricks of movement to which some 
persons acquire an uncontrollable impulse ; the peculiar rotatory and 
other rhythmical or irregular motions to which hysterical females are 
occasionally addicted ; and especially perhaps the redundant and awk- 
ward movements of locomotor ataxy. 

The clonic convulsions of epilepsy and epileptiform conditions are 
characterized by more or less violent and rapidly repeated alternating 
movements, by rapidly repeated alternate flexions and extensions of 
the arms or legs, or jerkings of the head and neck, or similar move- 
ments of the muscles of the face or of the eyes. These, like choreic 
movements, are not unfrequently unilateral, but they may be general, 
or limited to a single limb or part of a limb. 

In tonic spasm or convulsion, muscular contractions take place, 



874 



DISEASES OF THE NERVOUS SYSTEM. 



which are more or less enduring. It can readily be understood that 
the terms clonic and tonic can be employed only in a relative sense, 
and that clonic and tonic spasms pass one into the other by insensible 
gradations. Tonic spasms are exemplified in the cramps which occur 
after fatigue in the muscles of the calf, or in various muscles in Asiatic 
cholera ; in the contraction of the limbs which takes place in the course 
of some forms of paralysis; in the folding of the thumb into the palm, 
the gradual drawing up of the arm, or other comparatively slow and 
strong contractions of muscles, which are usually the earliest of the 
convulsive phenomena of the epileptic fit; and in the violent attacks 
of muscular rigidity which by their repetition constitute the character- 
istic sign of tetanus and strychnia-poisoning. 

It is not always easy to localize the seat of the diseases causing con- 
vulsions. In reference, however, to this point, it must be recollected 
that all those parts which by their destruction cause paralysis of 
certain regions, are necessarily likely under irritation to cause motor 
phenomena in the same regions. Thus, since hemiplegia is caused only 
by destructive disease of the opposite cerebral hemisphere (more es- 
pecially its anterior part) or of the corpus striatum or crus cerebri, it 
may be taken for granted that convulsions affecting generally one side 
of the body must be caused by disease of the same parts. It is proba- 
ble on this ground (but not on this alone) that choreic and epileptic 
convulsions, which are frequently unilateral, are of cerebral origin. 
Again, since paraplegia depends on disease affecting the cord, there is 
on that ground reason to suspect that convulsive affections presenting 
a similar arrangement are of spinal origin. Tetanus and strychnia- 
poisoning are cases in point, although it must be admitted that in both 
cases the lesion occupies the medulla oblongata as well as the cord it- 
self. When a single muscle or group of muscles is affected, we must 
look to the origin of the nerve or nerves which supply it; and it is 
clear that theoretically the lesion might be referred either to the nu- 
cleus of the nerve or to a limited spot either in the corpus striatum or 
in the gray matter of the cerebral convolutions in direct linear con- 
tinuity with the nerve-nucleus. It may be observed, however, that 
the simpler and more restricted in area such limited convulsion is, the 
more likely is it to be due to the influence of the nerve-nucleus ; the 
more complicated and so to speak purposive, the more likely is it to 
be traceable to the action of the corpus striatum or cerebral convolu- 
tions. The influence which certain areae of the cerebral surface have 
been shown experimentally to have upon certain combined movements, 
and Dr. Hughlings Jackson's pathological observations on the same 
subject, may aid us, in some cases, not only in determining that the 
lesion causing convulsions is cerebral, but in identifying the locality of 
the lesion. 

4. Hyperesthesia. Dysesthesia. 

Augmented or perverted sensibility has the same relation to the sen- 
sory part of the nervous system as spasms and convulsions hold to the 
motor, and indeed the two conditions are not unfrequently associated. 
Hyperesthesia means strictly exalted sensibility — a condition in which 



NUTRITIVE LESIONS IN NERVOUS DISEASES. 



875 



the various organs of sense are more readily affected than they should 
be by impressions which are made upon them, or in which the senso- 
rium is more appreciative than natural of the impressions which are 
conveyed to it from the organs of sense. Practically, however, ex- 
alted sensibility is scarcely if ever distinct from painful sensibility. 
The hyperesthetic eye cannot bear bright light, the hyperesthetic ear 
is affected painfully by powerful, high, or discordant sounds, the hyper- 
sesthetic skin shrinks from the slightest pressure or from mere contact. 
Hyperesthesia in this sense is not uncommon ; it is frequently observed 
in hysteria, sometimes in the early period of febrile disorders, occasion- 
ally in inflammatory and other affections of the central nervous organs. 
It is a common feature in hemiparaplegia, in which case not only is 
the paralyzed side generally still sensitive, but its sensibility often be- 
comes painfully acute ; it is common, too, in inflammatory affections 
involving the skin. Under the general term dysesthesia may be in- 
cluded a large number of abnormal sensations, referable to the ordi- 
nary sensory nerves, to the nerves of special sense, and to the sympa- 
thetic system, or at all events to the afferent nerves connected with the 
visceral organs. Among perverted sensations referable to the skin may 
be included sensations already adverted to as frequently indicating the 
advance of anesthesia, namely, numbness, sense of coldness, tingling, 
formication, and the like; as also itching, burning, cutting, stabbing, 
crushing, shooting, aching, constrictive and other pains, which are so 
common, and arise under so many various conditions that it would be 
a waste of time to endeavor to enumerate them all. True neuralgic 
pains are usually of a shooting character, flash w T ith momentary inten- 
sity along the fibres of the affected nerve, and occur in paroxysms 
composed of momentary shocks following one another in rapid succes- 
sion. Other varieties of dysesthesia are those which are manifested 
in relation to the visceral organs, among which may be included the 
besoin de respirer, which attends asthma and cardiac disease ; the agony 
of angina pectoris ; painful thirst or craving for food ; gastralgia, en- 
teralgia, and various indescribable sensations referable to different parts 
of the body, of which nervous and other patients complain, or which 
constitute many of the varieties of the so-called epileptic aura. Dys- 
esthesia of the organs of special sense may be indicated by the appear- 
ance of subjective phenomena referable to these organs ; of the eye, by 
the appearance of sparks or flames, or other objects, which may even 
present definite forms, be endowed with motion, and assume the visible 
attributes of living objects; of the ear, by the perception of sounds, 
such as humming, buzzing, singing, the ringing of bells, violent explo- 
sions, and even words and actual conversation ; and of the nose, by the 
perception of odors, of the taste, by the perception of flavors, for the 
development of which no extrinsic cause exists. 



5. Influence of Nervous Diseases over the Nutritive Processes. 

Sympathetic System— There is no doubt that the sympathetic system 
is largely concerned in morbid processes ; we know how importantly 
contraction of the bronchial tubes is connected with asthma ; we know 



876 



DISEASES OF THE NERVOUS SYSTEM. 



what an essential part contraction of the vessels plays in the production 
of the phenomena of. angina pectoris, and of the ansemia of the brain 
which precedes, as a rule, the epileptic attack; we know also how 
largely active and passive dilatations of vessels are concerned in in- 
flammation ; and that diabetes and some other disorders have been 
attributed to such dilatations and to consequent hyperemia of the 
liver or other organs. We need not, however, consider in detail the 
various pathological phenomena which are rightly or wrongly attrib- 
uted to the influence of the sympathetic nerves ; it is sufficient to say 
that these, so far as the vessels are concerned, solely determine varia- 
tions in diameter; that, if contraction take place, less blood reaches 
the tissues, which then suffer proportionately in their nutrition and 
functional activity ; that if, on the other hand, dilatation take place, 
the tissues become hypersemic and the various physiological processes 
proper to them stimulated into unwonted activity. Still, however 
much the affected parts suffer, temporarily or permanently, in their 
functional attributes, it does not appear that their nutrition becomes 
necessarily checked or perverted beyond the limits of health ; the 
anaemic tissues do not fall necessarily into degeneration or decay, the 
hyperaemie tissues do not necessarily pass into inflammation or patho- 
logical overgrowth. It must nevertheless be admitted that the hyper- 
aemie tissues when exposed to irritation are more liable to become in- 
flamed than healthy tissues are. 

Cerebrospinal System. — Admitting fully, however, the essential part 
which the sympathetic system plays in the regulation of the nutritive 
processes, both in health and disease, and admitting also the little 
obvious influence which the spinal system of nerves exerts over the 
same phenomena in health, it seems certain that it is to the spinal 
rather than to the sympathetic system that we must refer certain local- 
ized lesions which are apt to take place in the course of nervous dis- 
orders, and which we are now about to discuss. We refer more 
particularly to certain affections of the muscles, certain affections of the 
joints, certain affections of the skin and subjacent tissues, and certain 
affections of the viscera, especially the kidneys and bladder. 

1. Muscles. — We have already shown that in many cases of motor 
paralysis the implicated muscles retain their healthy texture, their 
bulk, and their contractility under the influence of stimuli, and, it may 
be, retain these qualities scarcely impaired for many months or for 
many years ; after awhile wasting to a slight extent from mere disuse, 
and possibly then undergoing some secondary fatty or other degener- 
ative change. Other cases of motor paralysis, however (cases for the 
most part of acute onset), are attended with rapid loss of electrical 
contractility and with concurrent acute wasting of the paralyzed 
muscles. These consequences may follow : first, on lesions of motor 
nerves; second, on disease of the cord; and, third, on cerebral disease; 
but they do not follow indifferently on all forms of disease or injury 
which affect these parts. Mere destruction of nervous tissue, however 
complete, does not seem to induce them ; nor have they relation to the 
completeness of the paralytic phenomena. They appear to be due 



NUTRITIVE LESIONS IN NERVOUS DISEASES. 



877 



solely to disease or injury causing more or less irritation in the nervous 
tissue which is its seat, and it may be added to disease or injury in- 
volving specially the motor nerves or the groups of large cells in the 
anterior cornua of the gray matter of the cord. If, therefore, muscular 
emaciation and loss of contractility be the consequences of lesion of a 
nerve, that lesion is almost certainly not a clean section, but the result 
of pressure, stretching, bruising, laceration, inflammation, or implica- 
tion in some growth. If they accompany spinal disease they are due 
to disease involving those special parts of the anterior cornua which 
have been already indicated, and involving, moreover, those groups of 
cells which are in direct relation by means of motor nerves with the 
affected muscles. No doubt many different forms of spinal affection 
are apt to be followed by muscular atrophy. Locomotor ataxy, dis- 
seminated sclerosis, and disease limited in the first instance to the 
lateral white columns, may each by horizontal extension involve the 
anterior cornua at certain points, and so induce irregularly distributed 
atrophic changes of the muscles; and, similarly, caries of the vertebrae, 
fracture of the spine, and tumors, may each of them, by pressure or 
otherwise, implicate the gray matter in their immediate vicinity and 
hence cause atrophy of the muscles supplied by the nerves emanating 
from the seat of lesion. Further, diffused inflammation, and haemor- 
rhage into the substance of the cord, both of which conditions may 
involve the central parts of the cord in a considerable length, may 
result in widespread muscular lesion. But the spinal affections which 
are the most common causes of muscular atrophy are those which in- 
duce infantile paralysis and equivalent conditions in the adult. In 
these the disease, which appears to be of an inflammatory nature, ap- 
parently originates in the groups of large cells, and even if distributed 
throughout the whole length of the cord may still be limited to them. 
Acute atrophy of muscles is comparatively rare as a sequela or conse- 
quence of cerebral disease, and when it occurs in this connection is 
probably always referable to some secondary descending lesion of the 
cord directly implicating the motor nuclei. It must be added that 
post-mortem examination seems to show that, in the particular form 
of wasting of the muscles here discussed, the implicated nervous tissue 
from the seat of lesion downwards appears to undergo (mainly in its 
connective-tissue elements) inflammatory proliferation, and that the 
initial change in the muscles is similarly an inflammatory hyperplasia 
of the connective-tissue elements and of the nuclei of the sarcolemma 
inducing a kind of cirrhosis, to which the diminution in the size of the 
muscular fibres is secondary. These fibres, though gradually becoming 
more and more attenuated, seem rarely, if ever, to lose their striation 
or to become fatty. 

2. Joints and Bones. — Irritative affections of nerves are sometimes 
followed by inflammation of joints, and of periosteum, which may ter- 
minate in disorganization and necrosis. But joint affections are occa- 
sionally also developed in the course of diseases of the cord and brain, 
in the members which are paralyzed. Charcot divides these joint 
affections into two groups. In the one the attack is acute or subacute, 
and attended with tumefaction, redness, and often more or less severe 



878 



DISEASES OF THE NERVOUS SYSTEM. 



pain. In the other the attack commences suddenly, with more or less 
diffused swelling of the limb, is attended with little or no pain, but 
involves the rapid erosion and disappearance of the cartilages and 
joint-ends of bones. The former of these affections has been met with 
in paraplegia from injury to the spine or from caries, and then most 
frequently in the knee. It has been observed also in hemiplegia, and 
mainly in the form of hemiplegia due to softening; it then occurs 
usually in the joints of the upper extremity, which it attacks as a rule 
from two to four weeks after the occurrence of paralysis and at the 
time when chronic contraction of the affected limb is taking place. 
This affection is essentially synovitis. The other form of the disease 
has been observed most frequently in persons suffering from locomotor 
ataxy, and in them for the most part at the onset of the symptoms of 
incoordination. It usually occurs in the knees, shoulders, or elbows, 
and is attended with much effusion into the joints, very rapid destruc- 
tion of the joint-surfaces, and not unfrequently dislocation. The 
processes here adverted to are not unlike those which occasionally at- 
tend rheumatism. The diagnosis, however, between the joint affections 
of nervous origin and those due to rheumatic inflammation is generally 
easy, if attention be paid to the limitation of the disease to the para- 
lyzed limbs, and to the concurrence of other trophic changes belonging 
to the same class. It must be especially noted that the joint affection 
is by no means unfrequently associated with rapid muscular atrOphy, 
and that there is ample reason for believing that it is due to irritation 
of the same nerves and the same part of the cord whose irritation 
causes the muscular lesion. 

3. Skin. — Various forms of inflammatory and other nutritive changes 
in the skin and tissues which are subjacent to it have been traced to 
affections of the nerves and nervous centres. It has long been recog- 
nized that, after division of the branches of the fifth pair distributed to 
the eye and conjunctiva, inflammation, leading to more or less rapid 
destruction of these parts, is apt to occur ; and that in cases of para- 
plegia attended with total abolition of sensation, inflammation, ulcera- 
tion, and gangrene are extremely liable to supervene in the paralyzed 
parts. It has been proved, however, by experiment on the lower 
animals, and by the results of careful attention to patients suffering 
from such lesions, that these inflammatory changes are not usually due 
to the withdrawal of any direct conservative influence which the healthy 
sensory nerves exercise over the parts to which they are distributed, 
but to the fact that the loss of sensation prevents the sufferers from 
recognizing the presence of mechanical irritants or other injurious in- 
fluences and so from avoiding or counteracting their operation. Various 
affections, however, more or less closely related to these last in their 
characters, are undoubtedly referable to the direct operation of irrita- 
tive affections of the sensory nerves, the cord, or the brain. These 
affections, or at least the most important of them, may be ranged under 
the heads of erythema, vesicular eruptions, bullous eruptions, atrophic 
changes, and gangrene. 

Cases are not unfrequently met with in which mechanical or other 
injuries to sensory nerves, not necessarily attended with anaesthesia, 



NUTRITIVE LESIONS IN NERVOUS DISEASES. 879 



but often, as might be supposed, with neuralgia, are followed by ery- 
thematous redness limited to the areae of distribution of the nerves, 
which redness may proceed to vesication, pustulation, ulceration, or 
gangrene. Such results have been observed in cases of tumors or 
inflammation involving the fifth nerve, and in cases also of injury or 
disease of certain of the sensory or mixed nerves of the arm or leg. 
One of the most interesting cases belonging to this group is that of 
! herpes or zona, limited to the distribution of a single sensory nerve. 
Another example of great interest is furnished, as Charcot has pointed 
out, by anaesthetic leprosy — one of the special features of which affec- 
tion is the excessive development of cellular elements in the course of 
the nerves, between the nerve-tubules. This overgrowth leads to the 
gradual destruction of the nerves and to consequent anaesthesia on the 
one hand and motor paralysis on the other ; but it leads also to atrophic 
changes in the muscles, and (what specially concerns us now) to ery- 
thematous patches of the skin, on which vesicles or bullae become 
developed, or which undergo atrophic changes ; and in some cases to 
gangrenous destruction of the skin, of the subjacent soft tissues, and 
even of the bones. 

[A peculiar atrophic alteration of the skin following injuries of the 
nerves of the extremities has recentlv been described, under the name 
of " Glossy Skin," by Mr. Paget and by Dr. S. Weir Mitchell, the 
latter of whom had many opportunities for observing it during the 
late American civil war. In well-marked cases the skin becomes 
smooth, hairless, almost devoid of wrinkles, glossy, pink or ruddy, or 
blotched, as if with permanent chilblains. The nails, too, become 
cracked and fissured, and have a tendency to retract away from their 
matrix. The skin thus altered is frequently the seat of an eruption, 
resembling, to a certain extent, eczema in character. It appears either 
as minute vesicles thickly scattered over the thin and tender cutis, or 
else in successive crops of larger vesicles on the skin about the altered 
parts. Associated with this condition of the skin there is a most dis- 
tressing form of neuralgia, to which Dr. Mitchell, in consequence of its 
burning character, has given the name of causalgia. He says of it, that 
its intensity varies from the most trivial burning to a state of torture, 
wmich can hardly be credited, but which reacts on the whole economy, 
until the general health is seriously affected. The part itself is not 
only subject to an intense burning sensation, but becomes exquisitely 
hyperaesthetic, so that a touch or a tap of the finger increases the pain. 
The patient generally guards the part carefully against exposure to the 
air 3 keeping it constantly wet with water, and finding relief in the 
moisture rather than in the coolness of the application.] 

In various lesions of the cord trophic affections of the skin are apt 
to take place. In locomotor ataxy, for example, according to Charcot, 
eruptions are occasionally developed, more especially during periods of 
exacerbation of the disease, and in connection with the occurrence of 
neuralgic pains. Indeed, he points out that the eruption is not unfre- 
quently limited to the parts to which the suffering nerve is distributed. 
Among special forms of skin disease thus arising he mentions lichen, 
urticaria, zona, and ecthyma or impetigo ; and we may add to the list 



880 



DISEASES OF THE NERVOUS SYSTEM. 



I 



erythema nodosum of unusual distribution. In this case Charcot attrib- | 
utes the cutaneous affection, as he does the pain, to the involvement, 
in the disease of the posterior columns, of the nerve-fibres passing 
through the outer part of these columns, previous to their emergence 
from the cord. Again, erythema in patches — which may go on to the 
development of vesicles (herpes), and thence to the formation of large 
bulla? (pemphigus) — is not uncommonly a consequence of that affection 
of the membranes of the cord termed " pachymeningitis," which during 
its progress compresses and irritates the cord itself and the roots of the 
sensory nerves. A similar general development of bulla? is sometimes 
met with in the course of vertebral caries. It may be added that ery- 
thematous, or vesicular, or pustular eruptions are occasionally developed 
in hemiplegic patients upon the paralyzed side of the body. 

The most important, and on that account the most interesting, of 
the cutaneous lesions consequent on paralysis are the patches of gan- 
grene which are commonly known as " bedsores." These are, of 
course, apt to form in many patients, whether paralytic or not, who 
are confined to bed, partly from the constant pressure to which promi- 
nent parts are under such circumstances exposed ; partly from the 
effects of the patients' secretions, which accumulate beneath them ; and 
in no small degree from the neglect of nurses. But there are certain 
paralytic cases in which bedsores form with remarkable rapidity — in 
the course of two or three days, it may be, from the commencement 
of the illness — and this without exposure to undue pressure, or to the 
irritation of urine or fseces, and in spite of the most watchful care on 
the part of the attendants ; moreover, the bedsores appear on the para- 
lyzed part, and on that alone, even if the un paralyzed parts have been 
specially exposed to pressure. The bedsores here referred to commence 
in the form of patches of erythema, with more or less inflammatory 
infiltration and congestion of the subjacent tissues, sometimes includ- 
ing the muscles and the bones. In a short time vesicles or bulla? 
appear upon them, and superficial sloughs form. These then gradu- 
ally extend in surface and in depth, and may thus eventually occupy 
a wide area, and involve muscles, bones, and even implicate subjacent 
cavities. Such bedsores may occur either in hemiplegia or paraplegia, 
and on any part of the paralyzed surface, but they arise more especially 
on such parts as are exposed to pressure. In hemiplegia they rarely 
appear except about the centre of the buttock. In paraplegia they 
specially involve the sacral region, and are hence situated on a higher 
level than those occurring in hemiplegia, and occupy a more central 
and symmetrical site. Moreover, in paraplegia they are apt to appear 
also on the heels, inside the knees, and upon the hips. The form of 
hemiplegia which acute bedsores tend specially to complicate is that 
due to haemorrhage. The spinal affections in which they more par- 
ticularly occur are those in which inflammation or haemorrhage involves 
a pretty considerable extent of the central portion of the cord. They 
may hence follow fractures and other injuries of the spine and exacer- 
bations or acute complications of chronic diseases. The formation of 
these acute bedsores must always be regarded as a phenomenon of 



ASCENDING, DESCENDING, AND COLLATERAL LESIONS. 881 



serious import ; but occasionally, of course, the morbid process be- 
comes arrested, and convalescence may supervene. 

The special seat in the cord of the lesions on which the various skin 
affections which have been enumerated depend has not been so accu- 
rately determined as the seat of those lesions which evoke affections of 
the muscles and joints. There are good grounds, however, for the con- 
clusion that the posterior cornua and central regions of the gray matter 
have the same trophic relation to the skin as the anterior cornua to the 
muscles. 

4. Viscera. — The visceral affections of chief importance referable to 
spinal lesions are inflammations of the bladder and kidneys, with the 
discharge of purulent, bloody, ammoniacal, and fetid urine. In most 
cases of paraplegia these conditions are no doubt apt to supervene after 
a time in consequence of the constant retention of the urine in the 
bladder, and the irritation to the mucous surface which results from its 
accumulation and decomposition. But there are certain cases of para- 
plegia in which the occurrence of this phenomenon is as early as the 
occurrence of bedsores, and in which, indeed, the two conditions take 
place simultaneously. The change in the quality of the urine and the 
inflammation of the kidneys and of the urinary passages cannot then 
be explained by simple paralytic retention or by spontaneous decompo- 
sition of the urine, and there is consequently little room left for doubt 
that they also are referable to the direct influence of the diseased spinal 
cord. 

Recapitulation. — It may be convenient here, by way of summary, to 
remark, first, that the pathological influence of the spinal nerves, of the 
spinal cord, and more remotely of the brain, upon the production of 
morbid changes in the muscles, bones, skin, and viscera is associated 
only with those lesions which are irritative in their effects or inflamma- 
tory ; secondly, that the lesions which immediately determine muscular 
and arthritic mischief are situated either in the course of the motor 
nerves or in their nuclei of origin; thirdly, that the lesions which im- 
mediately determine cutaneous, and probably also visceral, inflamma- 
tions involve either sensory nerves or the gray matter of the cord 
posterior to the central canal, or the immediately adjoining portions of 
the posterior columns of the cord, or possibly the ganglia at the base of 
the brain ; and, fourth, that although the variously situated spinal 
lesions and their respective pathological consequences have been sepa- 
rately considered, they are necessarily not unfrequently associated. 

6. Ascending, Descending, and Collateral Lesions. 

It is a fact of considerable importance, and one to which we havf? 
already more than once adverted, that circumscribed lesions of the brain, 
cord, and nerves tend to the production of degenerative changes either 
in the nervous tissue above them or in that below them, or in both ; 
and, further, that in the case of the brain or cord there may be hori- 
zontal extension. Thus apoplectic or other destruction of some portion 
of one of the cerebral hemispheres, and still more certainly similar 
destruction of the corresponding corpus striatum, lead to the occurrence 

56 



882 



DISEASES OF THE NERVOUS SYSTEM. 



of degeneration, which, commencing at the seat of disease, gradually 
extends downwards in a band-like form along the motor tract, first 
involving the corresponding eras and anterior pyramid, and thence 
passing to the opposite side of the cord and downwards mainly along 
the posterior part of the lateral white column. Again, when lesions 
occupy the lower part of the cord, they are apt to induce degenerative 
changes which gradually ascend in the posterior columns of the cord, 
and more especially in those parts of them which lie immediately on 
either side of the posterior median fissure. Further, lesions of interme- 
diate regions of the cord are liable to be followed by both ascending 
and descending degenerations; the former, as in the last case, limited 
to the posterior columns ; the latter, as in the first case, to the lateral 
columns. Occasionally also foci of disease involve secondary changes 
which extend from them in the horizontal direction ; and similar ex- 
tension would seem now and then to start from either the ascending or 
descending secondary lesion, so .as to involve more and more of the 
thickness of the cord, and thus more especially to involve the anterior 
cornua and their motor nuclei. 

When the anterior root of a spinal nerve is divided, its peripheral 
portion (at any rate its white substance) undergoes degeneration ; while, 
if the posterior root be divided, all the peripheral part — that which 
still retains its connection with the ganglion — remains healthy, while 
that which enters the cord degenerates. It may, however, be observed 
that, consecutively to amputation of limbs, the large cells of the an- 
terior cornua in relation with them have, after a considerable time, 
been found atrophic. 

It is obvious that the various secondary changes above described, 
and others which occur but do not as yet admit of being referred to 
any general rule, must necessarily, in many cases, induce special clin- 
ical phenomena, complicating more or less seriously those due to the 
primary lesion. 

7. Central and Reflex Consequences of Lesions of the Nerves. 

Not only are central lesions efficacious in the production of periphe- 
ral lesions, but lesions of sensory or centripetal nerves are capable of 
inducing central mischief, or by reflex action mischief in the area of 
distribution of centrifugal nerves. It is thus apparently that injury to 
sensory nerves induces that irritable condition of the spinal cord which 
forms the pathological basis of tetanus ; that intestinal irritation and 
the irritation of dentition causes convulsions in young children ; that 
certain uterine or ovarian conditions are instrumental in the production 
of the various psychical and motor phenomena which characterize hys- 
teria ; that renal affections involve paraplegia, and that injury to the 
frontal branch of the fifth nerve causes amaurosis. Brown-Sequard, 
who has devoted great attention to this subject, attributes indeed to 
reflex influence almost all the consequences w T hich are also caused by 
affections of the nervous centres : among others, various forms of paral- 
ysis, anaesthesia, deafness, loss of taste and smell, convulsions, delir- 
ium, and coma, together with cutaneous eruptions and wasting of 



HEADACHE. 



883 



muscles. It is perhaps needless to add that he, as well as others, 
attributes many internal inflammations to the influence of irritation 
acting reflectorially. 

8. Headache. 

Headache is a frequent attendant upon cerebral lesions, but it is still 
more commonly due to affections of remote organs, such as the stomach, 
or to neuralgic or rheumatic or other such conditions. In whatever 
cause the pain originates, or in whatever part of the head the cause 
operates, it seems pretty obvious that the pain must be referred to the 
peripheral distribution of the sensory nerves — that is, of those sensory 
nerves which have their apparent origin at the base of the encephalon, 
and which are distributed to the integuments, to the bones, and to the 
membranes of the brain. Thus some headaches are limited to one-half 
of the forehead, and probably to the corresponding eye — to the area of 
distribution of the first branch of the fifth ; some occupy both sides of 
the forehead, some affect the vertex, some the occipital region. Other 
headaches, again, appear to occupy the temples, and shoot from one side 
to the other; some are confined to the neighborhood of the ear, and 
others seem to be generally diffused. Headaches vary in character, 
and are variously described. Sometimes they are shooting, sometimes 
aching, sometimes throbbing, sometimes likened to a weight upon the 
top of the head, sometimes to a sense of constriction. It is needless to 
add that headaches are not unfrequently associated with intolerance of 
light and sound, visual spectra, and tinnitus aurium, vertigo, nausea 
and sickness, drowsiness or wakefulness, and sometimes (even if the 
affection be superficial and wholly independent of brain disease) with 
more or less delirium. It is in most cases exceedingly difficult to refer 
headache to its proper cause, unless our diagnosis be aided by the pres- 
ence of distinctive associated phenomena. Thus pain, almost accurately 
resembling in all its characteristics that of migrim, may be induced by 
the simple pressure of an unyielding hat upon the frontal branches of 
the fifth pair, and immediately cured by the removal of that pressure ; 
rheumatic neuralgia of the forehead, from simple exposure to a blast of 
cold air, is not unfrequently attended with a peculiar sense of drowsi- 
ness ; and in either case the pain may be so intense and so distracting 
as to lead the patient or his doctor to suspect serious disease of the in- 
ternal parts. Dr. Hughlings Jackson remarks that frontal headache 
is generally referable to abdominal affections, vertical headache to cere- 
bral disturbance, and occipital pains to disorders of the circulation, and 
more especially to anaemia. However that may be, it is certain that 
the pain due to cerebral disease may, especially in the case of cerebral 
tumors, be referred to all parts of the head, and that this pain may ex- 
actly simulate those w T hich are of less serious origin. It may be slight 
or intense, continuous or paroxysmal, may be attended with tenderness 
of the scalp, or with various of the symptoms which have been already 
referred to as frequent accompaniments of headache. When the pain 
is intense, and especially if it be paroxysmal, it frequently causes the 
patient to scream out, and to support his head with his hands. The 
most intense pain, which is then usually very limited as to its seat, is 



884 



DISEASES OF THE NERVOUS SYSTEM. 



induced by the pressure of intracranial tumors or abscesses upon sen- 
sory nerves. 

9. Vertigo. 

Vertigo, or swimming in the head, is that condition in which a 
person suffers from a sense of failing equilibrium, of falling or of ro- 
tating, and in which not unfrequently surrounding objects appear to 
swim or oscillate before his eyes. It has been attempted to distinguish 
between that form of vertigo in which the patient refers the vertiginous 
phenomena to his own person, and that in which he refers them to 
surrounding objects. The distinction is, however, obviously inadmis- 
sible. Vertigo may vary from a mere uncomfortable sense of oscilla- 
tion, such as one feels on landing after a sea-voyage, to a condition in 
which the patient is quite unable to maintain his equilibrium, and 
either falls to the ground, or is compelled to support himself by 
clutching some fixed object. It may be momentary or of long dura- 
tion, and in the latter case is commonly attended with exacerbations. 
It is generally more pronounced when the patient is standing or walk- 
ing, but may come on while he is lying down, and even has his eyes 
shut. The proximate cause of vertigo is probably multiform. Vertigo 
is often, and probably accurately, referred to variation or disturbance 
of the cerebral circulation ; in proof of which view it may be observed 
that it not unfrequently attends syncope, anaemia, and loss of blood, on 
the one hand, and cerebral congestion and inflammation on the other. 
It is not uncommonly the consequence of an unhealthy condition of 
the blood, or of the presence in it of poisonous matters : as appears 
from its frequent occurrence in inflammatory diseases and in the specific 
fevers. It attends epilepsy, eclampsia, and organic lesions, such as 
effusions of blood and tumors. It is frequently of eccentric origin, 
referable, for example, to dyspepsia or other functional derangements 
of the stomach. Physiological experiments have demonstrated that, 
in the case of the lower animals, injury, and more especially one-sided 
or unsymmetrical injury to the crura cerebri and other neighboring parts, 
is followed by vertiginous movements. It seems not improbable, there- 
fore, that similarly situated lesions in the human being might be attended 
with analogous phenomena. Affections of the cerebellum are, in large 
proportion, attended with vertigo. Affections of the eye and ear, and 
also of the spinal nervous system, are also capable of causing vertigi- 
nous phenomena. In the case of the eye, vertigo depends, for the most 
part, on affections involving the muscles, such as loss of power in one 
or more of the recti of one eye, in consequence of which a convergent 
or divergent squint is produced ; or on the presence of nystagmus. 
Vertigo referable to the ears is usually associated with deafness, and 
immediately clue, according to Meniere's researches, to disease of the 
semicircular canals, injury to which has been shown by experiment on 
the lower animals to be followed, equally with injury to the crura 
cerebri, by vertiginous movements. In reference to affections involv- 
ing the spinal nerves, it may be observed that the inco-ordinate move- 
ments of locomotor ataxy, and the oscillating movements of dissemi- 
nated sclerosis and of paralysis agitans, are not unfrequently attended 



APHASIA. 



885 



with the subjective phenomena of vertigo^ especially if their influence 
be not counteracted or neutralized by sight or hearing. Vertigo is fre- 
quently associated with headache, functional disturbance of the eyes 
and ears, sickness and other phenomena. The recognition of the causes 
on which vertigo depends must be based less upon the simple vertigi- 
nous phenomena than on the accompanying symptoms. 

10. Impairment or Loss of Power of Speech. (Aphasia. Aphemia. 

Amnesia.) 

We employ the above terms in their widest sense, and as including, 
therefore, not merely defects referable to, or manifesting themselves in, 
the organs of articulation, but defects relating to reading and writing. 
Paralytic affections of articulate speech may be divided into four classes : 
first, that in which the motor nerves of the organs of speech are para- 
lyzed in a greater or less degree, and where, therefore, the defect of 
speech is simply the result of inability to use these organs ; second, the 
class in which the co-ordinating centre of the movements of articula- 
tion is affected, and where the patient, having complete control over 
the movements of his lips and tongue for other purposes, is yet unable 
to utter articulate sounds ; third, the class in which the impairment of 
speech is central, where there is loss of memory of words, or amnesia, 
and other losses of mental attributes ; and, fourth, a complex class, 
including all those cases in which the conditions characteristic of the 
second and third classes are combined. 

The first class comprises a well-defined but rather wide range of 
cases, among which may be enumerated those of right or left hemi- 
plegia, general paralysis of the insane, general spinal paralysis, loco- 
motor ataxy, disseminated sclerosis, chorea, glosso-laryngeal palsy, and 
lesion of one or more of the motor nerves of the organs of speech. In 
left hemiplegia and in paralysis of one portio dura or hypoglossal, the 
defect of speech is often scarcely appreciable, and rarely amounts to 
more than a little thickness of utterance. In general paralysis there 
is usually a little tremulousness of the tongue and lips when the attempt 
to speak is made, a little hesitation and thickness or inexactness of 
utterance, which become especially marked when the patient speaks 
with vehemence. In locomotor ataxy and disseminated sclerosis the 
defect of speech may present some degree of variety ; in some cases 
there is more or less slowness and tremulousness ; in others the slow- 
ness is attended with exaggerated efforts on the part of the lips and 
tongue to effect their purpose ; in others the syllables are unnaturally 
divided, and there is a tendency, as it were, to scan the sentences ; but 
in all, even though separate letters may be accurately enunciated, the 
more complex their combinations in words the more clumsy and inex- 
act does their pronunciation become, and the latter parts of long sen- 
tences, or of a sustained conversation, always contrast unfavorably 
in these respects with the beginning. In glosso-laryngeal paralysis, 
the early stages of defective articulation resemble those observed in 
general paralysis, but gradually the lips and tongue and soft palate 
almost entirely lose their capacity of movement, and the patient loses 



886 



DISEASES OF THE NERVOUS SYSTEM. 



not only the power of articulation, but that of retaining the saliva in 
his mouth, -and that of swallowing. The character of the defective 
articulation of chorea need not now detain us. 

The second class of cases corresponds to the group to which Dr. 
Bastian endeavors to limit the use of the word aphemia, adopting the 
word from Broca, who, however, has employed it in a different and 
far wider sense. Typical cases of this kind are very rare. In them, 
patients recovering from an attack of unconsciousness are found to 
be entirely speechless, and to remain speechless for days, weeks, or 
even months, notwithstanding that they have regained the use of every 
other faculty which might be supposed to have any, the remotest, con- 
nection with speech ; that is to say, notwithstanding that they can hear, 
understand everything that is said to them, read, converse by means 
of writing, and use the lips and tongue with the utmost precision for 
every purpose excepting speech. Now in such cases as these it is 
obvious that the patient retains all his mental faculties, that he thinks 
(as is probably usual) with the aid of words, which he still retains the 
power of expressing by means of writing, but which he cannot utter; 
not because he has lost the use of his muscles of articulation, but 
because the wish to speak does not evoke the combined automatic 
movements on which speech depends. In ordinary conversation the 
words which express our thoughts flow automatically from our lips ; 
the complicated combinations of movements on which their utterance 
depends are executed momentarily and with the utmost precision, 
without any attention whatever being, as a rule, bestowed upon the 
movements themselves. 

Looking to the extreme complexity of these movements, it seems 
certain that that part of the brain in which words are transformed into 
ideas, and are revived in thought, acts, in the process of transforming 
them again into articulate speech, upon the centres of origin of the 
various nerves of speech, through the intermediate agency of a special 
co-ordinating centre. This centre is probably situated somewhere in 
or below the corpus striatum ; and within it, on the receipt of the 
message from above, the various telegraphic communications with the 
nerve-origins below are automatically so manipulated as to cause, 
through these latter, the organs of speech to execute the necessary 
combined movements. Words are practically innumerable; The ele- 
mentary articulate sounds, however, which by their combination pro- 
duce articulate language, are probably less than fifty in number, and 
this comparatively small number therefore also represents all the 
groups of simultaneous combined movements which the tongue and 
lips can be called upon to execute. It seems probable, partly on these 
grounds, partly from the consideration that language (apart from the 
mere mechanism by which it is uttered) is a mental function, and 
partly from the consideration that the function of a co-ordinating 
motor centre is to regulate or combine groups of movements, that the 
duty of the assumed co-ordinating centre of speech must simply be to 
preside over that essential but comparatively subordinate department 
of speech which consists in the production of the elementary articulate 
sounds. If this view be correct, it is easy to understand how some 



APHASIA. 887 

lesion involving this centre or cutting off the direct communication 
either between it and the intellectual centre of language above, or be- 
tween it and the nerve-nuclei below, might result in dumbness, while 
at the same time the command of language might in all other respects 
be perfectly retained, and the power of executing the most delicate 
movements with the lips and tongue remain intact. It is easy also to 
understand how, in such cases as this (considering that all articulate 
sounds are merely the results of certain mechanical arrangements of the 
speech-organs) the patient who has lost the power of speech might be 
taught to copy these mechanical arrangements, and thus again to speak, 
exactly as deaf mutes are taught. The morbid anatomy of this class 
of cases has not been yet investigated. The patients in whom aphemia 
has been observed have had fits, epileptic or apoplectic, from which 
they have recovered with or without temporary paralysis. 

In the third class of cases there is amnesia, or loss of memory of 
words. In typical examples of this kind the patient, with perfect 
power of utterance, is yet incapable, from want of words, of joining in 
conversation; with perfect vision he is unable to read even to himself; 
and with (it may be) entire command over his arm and hand, he can- 
not make himself understood by writing, or even write. In most, if 
not in all of these cases, however, there is not merely forgetfulness of 
words, but there is more or less inability to recall facts, to concentrate 
the thoughts, and to pursue any train of reasoning. An amnesic 
patient, when he attempts to speak, commences perhaps with one or 
tw T o words correctly uttered, then hesitates for a word, probably uses a 
wrong one, notices that be is wrong, tries to correct himself, perhaps 
repeats the words that he first uttered, stumbles a little, and then, with 
a gesture of annoyance, comes to a stop. If his attempt to speak be 
carefully observed, it will generally be noticed that his vocabulary is 
limited to a very few words, and that he tends to repeat certain of 
these, and especially to repeat certain combinations of them ; and in- 
deed he often appears to recall phrases more readily than single words. 
If asked to name even the most common things he fails in very large 
proportion, and fails probably to remember words which he has been 
taught to utter only a minute or tw r o previously. Yet he seems to 
understand everything that is said to him ; he at once distinguishes 
the right name from the wrong when submitted to the test ; and he can 
articulate readily every word which is dictated to him. It is very 
interesting to note that uttered words entering by the ear are by a vol- 
untary effort at once and perfectly reproduced by the organs of speech, 
and at the same time recall for the moment to his mind the ideas 
which properly attach to them. Such a patient may often be seen 
with a newspaper or a book, over which he pores as if he derived the 
greatest interest from its perusal ; but on asking him to read aloud he 
will probably indicate his inability to do so, and not even make the 
attempt; or possibly he may pick out a word here and there which he 
recognizes, and which he pronounces with more or less approach to 
accuracy. It might be supposed that, although he cannot translate 
written into vocalized words, yet that written words convey to his 
mind through the eye their proper meaning, and that hence he really 



888 DISEASES OF THE NERVOUS SYSTEM. 

understands what he reads. This, however, is generally not the case, 
for if he be examined by leading questions lie fails to show that he has 
any knowledge of what he seems to have been reading about. He 
will, however, not unfrequently point out here and there words, or 
even phrases, which he recognizes and perhaps utters. He seems, 
indeed, much in the condition of a child poring over the pages of a 
book written in a foreign language, which he has only begun to learn. 
If now asked to name the letters he probably fails to do this, just as 
he previously failed with words ; and, again, if asked to point out 
letters as they are named to him, his failure is equally marked. In 
fact, just as he has forgotten the names of things he has forgotten the 
names of letters, and consequently their value; and he fails, partly on 
this account and partly from the complexity of the mental process 
which it involves, to attach any sound or any meaning to the various 
combinations of letters which stand for words. When he recognizes 
printed words, it is probably as a whole that he generally recognizes 
them: thus, he will sometimes point out his own name, though unable 
to point to, or designate, a single letter that it contains. 

A similar difficulty exists in regard to writing. If his hand and arm 
be not paralyzed, or only slightly thus affected, he can execute all ac- 
customed delicate movements with them, and indeed can employ the 
hand as a mere machine just as well, probably, as ever he did. If he 
could draw, he can probably still draw, and he can copy the forms of 
geometrical figures, and therefore the forms of letters. He can write 
and print from a copy. If, however, he tries to write (and he is not 
unfrequently fond of writing) he either makes a series of unmeaning 
up and down strokes, manifesting even a dim recollection of the art of 
writing, or he begins a word, perhaps his own name, correctly, and 
after writing a letter or two repeats them and then stops, or passes on 
into unmeaning strokes. If words are dictated to him he writes them 
even more incorrectly than those which he writes voluntarily, and 
probably writes letter-characters which are dictated to him as faultily 
as words. Yet not unfrequently, if he be set to copy from a printed 
page, he will translate the printed words (letter by letter) into their 
written equivalents as well and as quickly as if he were in perfect 
mental health, and this without being able to name or to understand 
the printed words and letters, or those which he himself forms. It is 
curious to observe here the correspondence that exists between the eye 
and the hand : the patient sees the printed word, and by an effort of 
the will reproduces it automatically in written characters, yet neither 
the word he sees, nor its written equivalent, nor the act of writing it, 
brings to his mind, even for an instant, any glimpse of its meaning. 
An amnesic patient who is unable to write from dictation will often put 
down figures from dictation, and, further, perform simple arithmetical 
sums upon a slate with tolerable correctness. He may even perform 
sums in addition of money, and very curiously he will sometimes, while 
adding up, miscall the figures which he writes down correctly. 

Now the degree in which any one or all of the above peculiarities 
may be present in any case varies of course within very wide limits; 
and so also does the degree in which the patient's memory of facts and 



APHASIA. 



889 



power of concentrating his thoughts, and of reasoning, are retained. 
But the deficiency of the mental powers is not to be measured by the 
degree of loss of the memory of words. Many of those patients in whom 
the amnesic condition is extreme take such a lively interest in all that 
is going on around them, play at simple games of skill so cleverly, are 
so quick in their movements and in the use of their senses, and display 
such quickness of perception, that they obviously possess considerable 
intelligence. We are apt indeed to give them credit for much more 
intelligence than they really possess. It seems probable that, in pro- 
portion to their inability to recall facts and words by voluntary effort, 
they live more and more, as it were, in the objects which present them- 
selves to their senses, and in the evanescent ideas which they evoke. 

But many amnesic patients present peculiarities which do not quite 
accord with the above description — these peculiarities being due either 
to the degree in which the patient is affected or to the fact that other 
forms of sensory, motor, or mental derangement are superadded. Thus 
in some cases the aphasic condition is revealed only by the occasional 
misuse of certain words, or the omission of certain words or letters in 
speaking or writing, or by the occasional employment of wrong endings 
or beginnings to words, or by the transposition of syllables or letters, 
or by the use for the word intended of some other word having a phonet- 
ical relation with it, or some analogy to it either in its meaning, its 
appearance, or in the ideas which it evokes ; in other cases the patient's 
vocabulary is limited to one or two sounds or words, such as " yes " or 
"no," or to a phrase or two, such as "damn it," or "can't afford it," 
which he utters whenever he makes the attempt to speak, and some- 
times without appearing to recognize that his language is in any degree 
peculiar; in other cases the patient does little more than repeat words 
which are dictated to him, and these he repeats over and over again 
until a newly dictated word displaces the former one from his memory ; 
in other cases, again, he makes inarticulate sounds, which he utters 
volubly and with emphasis, and which, if carefully attended to, seem 
divided into lengths. These sounds, indeed, may have some obvious 
phonetic relation with words, and as the patient's condition improves 
become resolved into articulate speech. It may be added that amnesic 
patients not unfrequently utter an unexpected oath or phrase under the 
influence of emotional excitement, just as paralyzed patients under simi- 
lar circumstances are apt to move limbs over which they have no 
voluntary control ; and, further, that amnesic patients who have but 
few words at their command, when asked to repeat from dictation 
things that they have learnt, such as " the Lord's Prayer," the numerals, 
or the alphabet, will often, instead of repeating the word or sentence 
actually dictated, utter the word or sentence which immediately follows, 
and possibly continue their recitation until they become confused and 
mumble unintelligibly, or repeat themselves. It is this third group of 
cases, together w T ith the fourth group (to be considered presently) to 
which the investigations of M. Broca and others chiefly relate. It is 
in these cases that there is almost invariably right hemiplegia depend- 
ent on some lesion of the left cerebral hemisphere, occupying, roughly 
speaking, the district which the left middle cerebral artery supplies, 



890 



DISEASES OF THE NERVOUS SYSTEM. 



namely, the corpus striatum and the wedge of nervous substance ex- 
tending outwards, towards and including in its base the island of Reil 
with some of the neighboring convolutions — more precisely (according 
to M. Broca) the posterior third of the third frontal convolution. It 
is this district in which the effects of cerebral embolism are most fre- 
quent. 

The fourth group of cases includes all those in which amnesia is 
associated with aphemia, or with both aphemia and paralysis of the 
organs of speech. These cases are very numerous, and present great 
varieties of symptoms, according to the degree in which each of the 
above-mentioned conditions may be present, absolutely or relatively. 
In typical cases of this class, the patient, after an attack of right hemi- 
plegia, loses absolutely the power of speech, or at most utters some one 
or two inarticulate sounds, and perhaps has some difficulty in using 
the tongue and lips, but he apparently understands everything that is 
said to him, and when asked to point out words and letters on a 
printed page, probably points them out correctly. So far the symp- 
toms are those of aphemia. But presently the patient gradually or 
suddenly recovers the powers of articulate utterance, and it is then 
found that he is suffering from amnesia in addition to aphemia, that 
he has, in a greater or less degree, forgotten the names of things, per- 
haps his own name. 

In conclusion it may be suggested that it seems convenient still to 
employ the word " aphasia" in that general sense in which it has been 
used by Trousseau, as inclusive of all difficulties of speech which come 
under the second, third, or fourth of the above groups, and that, 
inasmuch as the aphasic condition thus defined includes two perfectly 
distinct clinical phenomena, which, though often combined, may exist 
separately, it seems also convenient to have a distinct name indicative 
of each of them, and applicable to those cases in which one or other of 
them occurs separately. The terms aphemia and amnesia may be thus 
employed. 

We may call attention to the facts that articulation and phonation 
are distinct elements in spoken language; that phonation in some 
degree survives in all cases of aphasia, and that not unfrequently 
aphasic patients who can utter only one or two words can yet hum 
tunes with facility ; and that loss or impairment of phonation is usually 
the result of disease directly involving the nerves of the intrinsic 
muscles of the larynx, or of hysterical and other such functional 
disturbances. 

11. Mental and Emotional Disturbances. 

It may be pointed out in conclusion that all forms of mental disor- 
ders are apt to attend not only brain diseases, but a large number of 
affections in which the brain is only secondarily or remotely impli- 
cated. This subject is much too vast to admit of separate discussion 
here. It may, however, be observed that patients may suffer in feel- 
ing, intelligence, and will, either conjointly or separately, and that 
these may be exalted, perverted, or impaired. Thus, as regards feel- 



INFLAMMATION OF THE DURA MATER. 



891 



ing, he may be excited (angry, boisterous, merry), depressed (melan- 
choly, anxious, fearful), or suspicious, mischievous, or sullen ; as 
regards intelligence, his ideas may flow rapidly and with vivacity, he 
may have delusions, his reasoning powers may be perverted or im- 
paired, his memory may fail, or there may be incoherence or general 
mental imbecility; and, as regards will, he may show abnormal ob- 
stinacy or tenacity of purpose, extreme vacillation, or utter listlessness 
and apathy, or incapacity for exertion. The various forms of delirium 
— the low muttering, the busy or garrulous, and the maniacal — are all 
common in different forms of disease. Insanity in all its varieties is 
apt to attend or supervene upon a large number of acute or. chronic 
disorders, whether these affect the brain or other parts. And lastly, 
coma — the abeyance of all mental phenomena — the condition in which 
the patient lies as in a profound sleep and insensible to every external 
influence, if not the primary disorder, constitutes the common fatal 
termination of most of the other mental affections which have been 
enumerated. 



INFLAMMATION OF THE CEREBRAL AND SPINAL 
DURA MATER. PACHYMENINGITIS. 

Causation. — Inflammation of the dura mater is either traumatic, or 
the consequence of the extension of disease from parts external to it, 
or it is of idiopathic origin. With traumatic inflammation the phy- 
sician has little to do. Inflammation from extension may be secondary 
to erysipelatous or other inflammation, commencing at the surface of 
the head, but is mostly traceable to caries of the petrous or mastoid 
portion of the temporal bone, or to similar affection of the frontal plate 
of the ethmoid or adjoining parts of the sphenoid or orbital parietes, 
or to syphilitic or other like affections of the bones of the skull, or to 
caries of the vertebra?, or to sacral bedsores. 

Morbid Anatomy. 1. Cerebral Dura Hater. — When inflammation 
extends from the bones of the skull to the dura mater this membrane 
becomes thickened and softened, and its connection with the subjacent 
bone more or less loosened. A false membrane not unfrequently forms 
upon its free aspect, and may cause it to become adherent to the corre- 
sponding surface of the brain. Sometimes suppuration takes place 
here, and may then either be limited by adhesions, or become diffused 
over a comparatively wide area. Not unfrequently inflammatory over- 
growth or actual suppuration takes place between the skull and the 
dura mater, and in the latter case the dura mater is apt to become per- 
forated, and the pus to be discharged into the cavity of the arachnoid. 
When the inflammation occurs in the neighborhood of the sinuses, 
these are liable to get involved and to become the seat of thrombosis 
or of suppuration, or the source of pysemia. This event is especially 
common when the meningitis is due to disease of the temporal bone, in 
which case the lateral, petrosal, or cavernous sinus may either or all of 
j them suffer. 



892 



DISEASES OF THE NERVOUS SYSTEM. 



2. Theca Vertebralis. — The inflammatory products which are de- 
veloped during the progress of vertebral caries tend sooner or later to 
accumulate in the neighboring part of the vertebral canal, between the 
bones and the dura mater. In the majority of cases, according to M. 
Michaud, this accumulation takes place in the first instance between 
the back of the bodies of the vertebrae and the vertebral ligament, 
which latter gradually undergoes erosion and perforation. The theca 
vertebralis then becomes involved in the inflammatory process, the 
outer surface of its anterior portion undergoing proliferation, and pos- 
sibly forming a kind of caseous button, which, when the cord becomes 
compressed in this disease, constitutes for the most part the agent of 
that compression. Inflammation of the dura mater, secondary to ver- 
tebral disease, may of course occur in any part of the length of the 
spinal column. In patients who are suffering from extensive bedsores 
of the sacral region, it frequently happens that the sacral and coccygeal 
bones are exposed and eroded. In some of these cases the sacro-coc- 
cygeal ligament becomes destroyed, and the inflammatory process ex- 
tends into the vertebral canal, or in consequence of perforation of the 
theca vertebralis, into the cavity of the arachnoid. Occasionally, con- 
secutively either to vertebral disease, or to the condition last mentioned, 
or from some idiopathic cause, the theca vertebralis becomes inflamed 
throughout, or in a great part of its extent, and suppuration takes 
place on either side of it. The pus which forms externally accumu- 
lates first in the spinal canal, and then (if the case be of sufficiently long 
duration) escapes with the nerves through the intervertebral foramina, 
and follows their primary ramifications ; forming, it may be, a longi- 
tudinal series of abscesses behind on either side of the vertebral spines, 
and a similar series in front on either side of the bodies of the vertebrae, 
those in the abdomen possibly constituting multilocular psoas abscesses. 
The pus which is effused from its inner aspect distends the cavity of 
the spinal arachnoid, and may rise thence into the arachnoid cavity at 
the base of the brain. 

Whenever the pus which is diffused throughout the arachnoidean 
cavity is derived from gangrenous sources, or from areae of disease 
which communicate with the external atmosphere, it is fetid, greenish 
in hue, and dirty-looking, and on post-mortem examination the surface 
of the brain or cord in relation with it is generally found stained to a 
greater or less depth by imbibition. This peculiarity is most frequently 
observed in meningitis due to perforation of the theca vertebralis by 
bedsores, and in that which takes place consecutively to chronic ear- 
disease, and is occasionally met with in other varieties of caries of the 
skull or vertebrae. 

3. Pachymeningitis. — A peculiar chronic form of inflammation of 
the dura mater of the brain or cord is now usually termed pachymenin- 
gitis. It may be the consequence, as are the varieties of meningitis 
just discussed, of injury or subjacent disease. It is more commonly, 
however, of spontaneous origin. In the head it commences, for the 
most part in the area of distribution of the middle meningeal artery, 
with the formation over a greater or less extent of surface of a delicate 
adherent film, which consists partly of embryonic corpuscles, but mainly 



INFLAMMATION OF THE DURA MATER. 



893 



of large irregular thin- walled capillaries. Other similar films become 
developed in slow succession one upon the other over the diseased area, 
until the adventitious formation attains considerable thickness; the 
deeper-seated laminae meanwhile becoming denser, more fibrous, and 
less vascular. Owing to the large size and extreme delicacy of the 
newly-formed bloodvessels, rupture, with extravasation of blood, is of 
frequent occurrence. For the most part the haemorrhages are minute 
and numerous, and result in the precipitation of crystalline and other 
forms of blood-pigment ; not unfrequently, however, they are abundant, 
and form large accumulations between the laminae, giving, it may be, 
to the whole growth the aspect of a mere clot. 

Pachymeningitis of the theca vertebralis usually takes place in the 
neighborhood of the cervical enlargement of the cord. The dura 
mater becomes greatly thickened by the formation of a series of con- 
centric fibroid laminae, successively developed upon its inner aspect. 
All of them, even the most recent, are dense and tough, and little 
vascular or inclined to bleed, and thus differ from those occurring in 
the cerebral dura mater. In the progress of the disease the pia mater 
is apt to become involved, and sooner or later the cord gets compressed, 
and the nerves in their passage to the intervertebral foramina also im- 
plicated. 

Symptoms and Progress. — The symptoms which attend inflammation 
of the dura mater are necessarily vague, unless the inflammation be 
suppurative, or have extended to the pia mater, bloodvessels, or subja- 
cent nervous matter, or involve the compression of the nervous centres, 
or of nerves. They are especially vague, if not trivial and misleading, 
in the earlier stages of the chronic forms of the disease. If suppura- 
tion take place febrile disturbance with rigors is likely to ensue; and, 
as has often been observed, the fever, is then very often of an irregu- 
larly remittent or even intermittent type, and the patient's illness may 
thus for a time present no little resemblance to an attack of ague. If 
the inflammatory mischief go on to the effusion of inflammatory prod- 
ucts into the cavity of the arachnoid, or to the involvement of the pia 
mater or substance of the brain or cord, or of nerves, special symptoms 
referable to these several parts will of course be developed. We pro- 
ceed to consider seriatim the symptoms of the different varieties of 
inflammation of the dura mater, the morbid anatomy of which we 
have already passed in review. 

1. Acute inflammation of the cerebral dura mater is almost always, 
in medical practice, due to chronic disease of the ear. Eecent otitis, 
however intense, is rarely followed by it. The patient, who may be 
of any age between early childhood and advanced life, has suffered 
probably for years, perhaps nearly all his lifetime, from deafness of 
one ear, attended with discharge, more or less constant, more or less 
copious, and more or less offensive, from it, and occasional attacks of 
earache. 

The supervention of meningeal mischief is sometimes induced by 
exposure to cold, sometimes by a blow on the affected side of the head, 
and not unfrequently seems to occur spontaneously. Very often it is 
preceded by or attended with sudden diminution or cessation of dis- 



894 



DISEASES OF THE NERVOUS SYSTEM. 



charge. The patient is usually first attacked with intense pain in the 
affected ear or its neighborhood, or possibly severe headache referable 
to some other part of the head. The pain, which is generally more or 
less constant, is attended with exacerbations which are often so violent 
that he shrieks out in his agony. Not unfrequently it continues as 
long as the patient retains consciousness ; but it often remits or disap- 
pears, and in some cases is wholly wanting from first to last. It is 
probably for the most part referable to the ear disease rather than to 
that of the internal parts. Sometimes a paroxysm of convulsions is 
the earliest specific indication of brain mischief; sometimes vomiting; 
sometimes an attack of vertigo, incoherence, or rambling ; sometimes 
a rigor. The progress of the case is subject to remarkable variations 
both as to duration and as to the phenomena which attend it. As- 
suming it to prove fatal, the patient may die in the course of two or 
three days ; more commonly he survives for two or three weeks ; but 
his life may be prolonged for several months. In the last case inter- 
vals of apparent restoration to health probably occur ; thus, in some 
instances, the patient has a convulsive attack, attended perhaps with 
vomiting, from which he recovers, and a second attack, which proves 
the precursor of fatal symptoms, does not take place for some days 
or weeks ; in some instances he complains of strabismus and double 
vision, which may disappear from time to time, but are finally asso- 
ciated with graver phenomena; in some he actually suffers from a 
combination of symptoms threatening speedy dissolution, from which, 
nevertheless, he emerges, but only to become sooner or later the victim 
of a relapse. 

The symptoms of the established disease comprise, in addition to 
headache localized in the ear, or occupying the forehead, vertex, or oc- 
ciput, or other parts of the head, vertigo, intolerance of light and 
sound, hyperesthesia, neuralgic pains in the head, neck, and limbs, 
nausea and vomiting, sleeplessness, restlessness, and irritability, mutter- 
ing, busy or maniacal delirium, convulsions, local or general, occur- 
ring at rare intervals or following one another in rapid succession, 
paralysis limited to certain of the cerebral nerves or hemiplegic, drow- 
siness and coma, together with febrile symptoms. But these are not 
all necessarily present in the same case. Occasionally the patient, after 
suffering from severe pain in the ear, and possibly indefinite symptoms 
of brain affection, falls into a state of collapse ; sometimes he suffers 
mainly from convulsions, which are attended or succeeded by paralysis 
and coma ; sometimes paralytic symptoms are the main feature of the 
malady — he becomes hemiplegic or has paralysis of some of the mus- 
cles of one of the eyeballs or of the portio dura, or he has difficulty 
in speech or deglutition, or he loses the sight of one or both eyes ; 
sometimes he suffers mainly from mental derangement ; sometimes he 
has frequent and severe rigors, coming on at more or less regular inter- 
vals, with other febrile symptoms, such as coated tongue, heat and 
dryness of skin alternating with perspirations, rapid pulse, and the like. 
In other cases the skin is cool, the pulse of normal rate, and there is 
total absence of febrile reaction. 

The differences of symptoms which different cases present are in 



INFLAMMATION OF THE DURA MATER. 



895 



great measure no doubt attributable to differences in respect of the 
depth or superficial extent to which the inflammatory process extends 
within the skull. It is certain that if the inflammation be limited to 
the dura mater, even if this becomes sloughy and pus accumulate be- 
tween it and the bone, the symptoms are in a large number of cases 
undistinguishable from those due to otitis alone, and may be uncom- 
plicated with fever. Again, if inflammation reach the free surface of 
the dura mater, and especially if pus escape into the arachnoidean 
cavity, it is natural that aggravated brain symptoms should be sud- 
denly excited, that more or less fever should be developed, that some 
of the nerves at the base of the brain should become implicated, and 
that some of the symptoms of cerebro-spinal meningitis, such as retrac- 
tion of the head and pain on moving it, should be experienced. Fur- 
ther, if abscesses form in the contiguous brain substance, symptoms 
due to their presence are likely to arise. When inflammation of the 
dura mater involves thrombosis of the sinuses which are contained in 
its laminae, the escape of blood from some part of the brain may be to 
some extent impeded ; the most interesting phenomena, however, are 
those which are referable to the veins of the face and neck which are 
in continuity with the obstructed sinuses. Thus it sometimes happens 
that the veins in the eyelids and conjunctiva of the affected side are 
pretern at u rally distended with blood ; sometimes that inflammation 
of the internal jugular in the neck occurs, and that consequently deep- 
seated abscesses form in that situation. Lastly, pyaemia is not unfre- 
quent ; and, although rigors may be caused by local suppuration or by 
the effusion of pus into the arachnoid, they are most frequently an in- 
dication that the affection of the ear has become complicated with 
purulent infection. 

It may be added that the pulse is liable to great variations, that it is 
generally accelerated, but may be of normal rate throughout, that it is 
sometimes preternaturally slow, and generally, when death approaches, 
becomes greatly accelerated and feeble ; that the skin is sometimes hot 
and dry, but often perspires profusely, especially towards the close, and 
that generally during the course of the disease Trousseau's "tache 
c6rebrale" can be elicited; that the tongue differs in its character, is 
often natural, but tends to become coated, and with the approach of 
death dry and brown ; that the evacuation of the urine and faeces is 
often performed unconsciously ; and that in the course of the disease 
symptoms are sometimes relieved by the sudden discharge of pus from 
the ear or even from the nose. 

Death is usually due to collapse or to coma ; it may, however, be 
caused by asphyxia, or be traceable to the effects of pyaemia. 

2. Pachymeningitis of the Cerebral Dura Mater, — The symptoms 
which attend this disease are exceedingly vague, and none the less so 
that it usually affects aged persons in a state of imbecility or dementia. 
It has been observed also, according to M. Lancereaux, in cases of 
chronic alcoholism and chronic pulmonary phthisis. The symptoms 
include more or less pain in the head, vertigo, failure of the mental 
powers, gradually increasing hemiplegia, with occasional epileptiform 
or apoplectic attacks, in one of which the patient probably dies. 



896 



DISEASES OF THE NERVOUS SYSTEM. 



3. Acute general imflammation of the theca veriebralis, such as results 
from its perforation by a bedsore, or the extension of inflammation 
which occasionally follows fracture or caries of the spine, is sometimes 
attended with marked symptoms, but is often extremely obscure in its 
indications. The symptoms which maybe looked for are: more or 
less pain in the course of the spine, sometimes of an exceedingly in- 
tense character, and for the most part liable to great aggravation by 
any movement, voluntary or involuntary, of the limbs or of the trunk 
or of the head and neck ; more or less rigidity of the muscles, with 
perhaps twitching; and at the same time loss of motor power and 
probably of sensation and of control over the bladder and rectum. To 
these, cerebral symptoms are apt to be superadded, more especially de- 
lirium, convulsions, and coma. Further, there may be tenderness in 
the course of the spine, due partly to the disease within it, partly, per- 
chance, to the extension of suppuration into the muscles of the back. 
In cases of sufficiently long duration and sufficient intensity, it is possi- 
ble that psoas abscesses may be discernible by palpation in the neigh- 
borhood of Poupart's ligament. When the inflammation is due to the 
extension of bedsores which have become developed during the prog- 
ress of paralytic or other diseases, attended with impairment of the 
mental faculties, its presence is almost certain to be overlooked. More 
or less febrile disturbance will probably always be present. 

4. Caries of the vertebrce, even when it is attended with considerable 
displacement, does not usually of itself cause paralysis. The para- 
plegia, indeed, which so commonly attends the disease, is almost in- 
variably due to the extension of the inflammatory process to the mem- 
branes of the cord and to the cord itself, and to pressure caused by the 
accumulation of inflammatory products. 

Among the early symptoms of involvement of the nervous contents 
of the spinal canal (in addition to local pain and tenderness, and possi- 
bly angular curvature, indicative of the affection of the bones) must es- 
pecially be noticed burning pains in the course of some of the nerves 
springing from the implicated portion of the cord. These pains, ac- 
cording to the situation of the disease, may involve the nerves of one 
or both shoulders or arms, or one or both great sciatic nerves, or certain 
of the intercostal nerves or of those of the abdominal walls. They are 
liable to come and go, and when continuous are often attended with 
exacerbations ; moreover, there may be more or less hyperesthesia in 
the area of their distribution. The sense of constriction, often likened 
to the feeling as of a cord drawn tightly round the chest or abdomen, 
which is so commonly complained of by paraplegic patients, belongs to 
the same category. These morbid sensory phenomena are due to in- 
volvement of the sensory roots of the spinal nerves, which generally 
occurs before the cord itself suffers; and it not uncommonly happens 
at this period that erythematous or vesicular eruptions or pemphigus 
become developed in the area of distribution of the affected nerves, and 
even beyond that area. It need scarcely be said that the motor 
branches may be equally involved, and that limited atrophy of muscles 
and limited motor paralysis may ensue. If the disease occupy some 
considerable length of the spinal canal, or a part in which nerves only 



INFLAMMATION OF THE DURA MATER. 



897 



are present, the several phenomena due to implication of nerves alone 
may become pretty widely distributed. Thus, if (as not unfrequently 
happens) the disease occupy the situation of the cervical enlargement, 
there may be hyperesthesia, burning pains, and cutaneous eruptions, 
involving one or other or both arms, with flaccidity and wasting of the 
muscles, and rapid loss of electric contractility, followed after a time 
by anaesthesia and complete motor paralysis of the same parts, but 
without any involvement whatever of the lower part of the body ; if it 
be in the situation of the cauda equina, one or both lower extremities 
will probably suffer in the same manner as the arms in the former case. 
In either case there will be a total absence of reflex movements in the 
affected limbs. 

After a time, which varies considerably in different cases, symptoms 
due to involvement of the cord come on. These consist, in the first 
instance, in numbness, tingling, or formication in the affected limbs, 
together with some impairment of muscular power. The latter in- 
creases, as a rule, more or less rapidly until complete motor paralysis 
is established. The impairment of sensation, on the other hand, for 
the most part remains stationary, or undergoes some amendment, or 
varies from time to time. Sometimes, however, it goes on to absolute 
anaesthesia. The muscles before the seat of disease, even if there be 
total abolition of sensation and motion, retain more or less of their 
natural tonicity and plumpness; their electric contractility remains 
normal or becomes increased ; and reflex movements may, as a rule, be 
much more readily induced in them than in health. Such movements 
are, indeed, often provoked by the contact of the bedclothes, or by the 
passage of evacuations. If the involvement of the cord persist, the ordi- 
nary ascending and descending lesions take place, the former along the 
posterior median columns, the latter along the lateral columns. The 
progress of these complications is attended with and indicated by aggra- 
vation of the reflex phenomena, and especially by the occasional occur- 
rence of tremulous movements, lasting for many minutes at a time, in 
the affected limbs; by the supervention from time to time of clonic 
or tonic spasms, and by gradually increasing rigidity of the muscles, 
which in the first instance goes along with extension of the limbs, but 
at a later period with flexion. 

The symptoms which attend the form of paraplegia under considera- 
tion present considerable differences, partly in dependence upon the 
situation of the spinal caries, partly upon the degree in which the 
cord is involved. Thus, when the disease is in the dorsal or lumbar 
region, one lower extremity only may be involved, or the two ex- 
tremities may be involved in different degrees, or there may be 
cross paralysis, with loss of motion on one side and impairment of 
sensation on the other; when the disease is in the neck the arms 
are commonly affected prior to the legs, and they may be involved 
unequally ; and, even when legs and arms are all implicated, the par- 
alytic phenomena in each may present differences in degree and dif- 
ferences in kind. Thus, again, while the rectum and bladder are often 
little, if at all, compromised when the lumbar or lower dorsal region is 
affected, want of control over these viscera is usual when the disease 

57 



898 



DISEASES OE THE NERVOUS SYSTEM. 



involves the upper dorsal or cervical region; and, indeed, in the latter 
case this want of control occasionally precedes all other paralytic symp- 
toms. Further, when the cervical spine is the seat of disease, various 
phenomena, of more or less interest or importance, are apt to be super- 
added to the simple paraplegic symptoms, among which may be enu- 
merated affection of the pupils of one or both eyes — in the first instance 
dilatation, at a later period, and more commonly, contraction; cough, 
difficulty of breathing and of speech; difficulty of deglutition, hic- 
cough, vomiting and gastralgia ; epileptic attacks, and permanent slow- 
ness of the pulse, with frequent tendency to faint. 

The prognosis of paraplegia dependent on caries of the vertebrae is, 
so far as the paralysis is concerned, not unfavorable: that is to say, 
presuming that the patient is not carried off by the effects of long- 
continued suppuration or of degenerative changes in internal organs, 
or by pulmonary phthisis or other complications, there is always good 
reason for anticipating, in a case that comes under early observation, a 
more or less complete restoration of motion and of sensation. Cures 
have often been effected in patients who had been completely paralyzed 
for one or two years, or even longer. And, indeed, it has been shown 
by anatomical evidence that substantial recovery has occurred in cases 
in which the cord has been permanently reduced in diameter by pres- 
sure, and impaired in its texture by interstitial growth, or by the de- 
velopment of secondary ascending and descending lesions. It is obvious 
that those patients who have caries of the cervical vertebra? incur many 
more, and more serious, risks than those who suffer from dorsal caries ; 
and it may be added that when the atlanto-axial articulation is the seat 
of disease sudden death from rupture of the ligament and consequent 
sudden compression of the upper extremity of the cord is to be dreaded. 
Apart from the causes of death which have already been enumerated, 
paraplegic patients are apt to sink from the effects of bedsores, or from 
the consequences of vesical and renal inflammation. 

5. The symptoms referable to cervical pachymeningitis are not unlike 
those which sometimes attend cervical caries. The affection presents 
two stages. The first, or painful stage, which lasts two or three 
months, is characterized by extremely acute pains in the back of the 
neck, shooting thence to the head and along the upper extremities. 
These are for the most part constant, but liable to exacerbations. The 
pains are attended with rigidity of the muscles, most strikingly mani- 
fested in those of the neck, which is kept fixed in a position identical 
with that which is assumed in cervical caries. At the same time the 
patient complains of formication, and a sense of weight in the limbs, 
and more or less loss of muscular power. Bullous eruptions, too, are 
not unfrequent. The above phenomena are due to compression and 
irritation of the nerves. In the second stage the nerves become more 
or less disorganized, and the spinal cord compressed. The limbs cease 
to suffer pain, but the muscles become paralyzed and undergo atrophy. 
It is, however, remarkable that the muscles of the forearm supplied by 
the musculo-spiral and median nerves for the most part specially suffer, 
those, however, supplied by the former nerve being less affected than 
those supplied by the latter. It results from this that the extensors of 



INFLAMMATION OF THE DURA MATER. 



899 



the hand predominate over the flexors, and that the hand consequently 
assumes the form of a claw. This peculiarity, though not special to 
cervical pachymeningitis, is special to it among diseases of spinal origin 
causing muscular atrophy. Subsequently contractions of the affected 
limbs take place, and patches of anaesthesia appear in them and on the 
upper part of the trunk. Later the lower extremities become paralyzed 
and contracted, but do not undergo atrophy. 

Treatment. — The treatment of inflammatory affections of the dura 
mater and of the affections so commonly associated with them is on the 
whole unsatisfactory. We have, as a rule, little or no direct influence 
over the progress of acute internal inflammation; and chronic inflam- 
matory processes occurring in deepseated parts are equally rarely 
amenable to direct treatment unless they be due to certain specific 
diseases. 

1. If we have reason to suspect the presence of circumscribed sup- 
puration between the dura mater and bone, or in the parts immediately 
internal to the dura mater, the question of aiding its escape will natur- 
ally present itself. If, therefore, the patient have a scalp wound, or 
be suffering from fracture or necrosis, or syphilitic affection of any part 
of the skull, it will probably be deemed advisable to apply the trephine. 
If the source of mischief be seated in the ear, that organ must be care- 
fully examined; if there be evidence of accumulation of matter in the 
tympanum, the membrane, assuming it to be whole, should be punc- 
tured or incised; if it be already perforated and the discharge offensive, 

! the cavity should be washed out carefully with antiseptic solutions; if 
there be evidence of suppuration in the soft parts about the mastoid 
process, or behind the angle of the jaw, a free incision should be made ; 
and, further, if we have reason to suspect the presence of pus in the 
mastoid cells, these should be laid open by means of the trephine. But 
the inflammation is not always suppurative; and the application of 
leeches over the mastoid process or in its vicinity often affords some 
relief, especially in the early stage of the disease, and may possibly 
tend to arrest its progress. Hot fomentations and poultices to the part 
are also not unfrequently grateful to the patient, and they may be ren- 
dered more so by the addition to them of opium, belladonna, aconite, 
or other preparations having sedative properties. Evaporating lotions 
or ice to the head are generally also serviceable. As regards internal 
treatment, it is well in the first place to maintain free action of the 
bowels, and to restrain as far as possible sickness or other distressing 
symptoms. Iodide of potassium may also be administered. There is 
a genera] feeling against the employment of narcotics in these cases ; 
we must declare, however, that we have often seen much relief to agony 
and restlessness afforded by the exhibition of largish doses of laudanum 
i or morphia, and never any injurious consequences. If the affection 
I take a chronic or subacute course, it may be well to administer iron, 
preferably perhaps the syrup of the iodide, or quinine, or cod-liver oil, 
| and to have recourse to counter-irritants. The patient should of course 
j be kept extremely quiet, be carefully watched, and his diet and secre- 
tions regulated. 

2. The treatment of cerebral pachymeningitis is that of old paralysis 
and other chronic organic lesions of the brain. 



900 



DISEASES OF THE NERVOUS SYSTEM. 



3. In the local treatment of general acute inflammation of the theca 
vertebralis, leeching, fomentations, the application of ice and counter- 
irritation may be enumerated; but more important perhaps than any 
of these is the maintenance of the patient at perfect rest, either on his 
back, or in a position midway between the back and side. Iodide of 
potassium may be administered here as in the former case; but tonics, 
stimulants, and opium are more likely to be of service. 

4. Paraplegia from vertebral caries must be treated by absolute rest 
in the supine position, on a bed specially adapted to the case and with 
suitable arrangements for the discharge of the patient's evacuations 
without the need of movement. And this rest must be maintained for 
a considerable period ; indeed, as has been already remarked, a period of 
one or two years or more may elapse before even a trace of returning 
muscular power can be observed. In addition, counter-irritation to the 
neighborhood of the part affected appears often to be of essential service; 
the best forms are issues, which should be kept open, or the actual or 
galvanic cautery, applied on one or both sides of the spine. The general 
health of the patient should be maintained by good diet, stimulants, 
and tonics ; and great care should be taken to prevent the supervention 
of bedsores and of inflammation of the bladder. If the muscles show 
signs of wasting from disuse, the employment of Faradization or of the 
direct current may be had recourse to — a treatment which may also be 
beneficial in promoting recovery when recovery is in progress. 

5. Spinal pachymeningitis should be treated on the same principles 
as paraplegia from caries. 



CEREBRAL AND SPINAL MENINGITIS. TUBERCULAR 
MENINGITIS. (Acute Hydrocephalus.) 

Causation. — The causes of meningitis are various. In some cases it 
depends on the spread of inflammation from adjacent parts, from the 
brain or cord itself, or from the dura mater or the bones, or more es- 
pecially from the internal ear ; indeed, these latter affections rarely pro- 
duce cerebral symptoms without involving the pia mater to some ex- 
tent. In some cases it is secondary to the presence of adventitious 
products, such as miliary tubercles, tumors, and apoplectic clots. It 
may be the result of injury or of direct exposure to the rays of the sun. 
It is sometimes of idiopathic origin, sometimes due to pyaemia, and 
sometimes (as apparently in epidemic cerebro-spinal meningitis) pro- 
duced by contagion. Tubercular meningitis, which is in fact by far 
the most common form of cerebral meningitis, may occur at any date 
between early infancy and old age. It probably, however, occurs most 
frequently before puberty ; but is common up to thirty. 

Morbid Anatomy. — 1. Cerebral meningitis is characterized essentially 
by dilatation and hyperemia of the vessels of the pia mater, and the 
effusion of coagulable lymph and inflammatory corpuscles into the 
meshes of the subarachnoid tissue. The first naked-eye evidences of 
inflammation are furnished by the presence of congestion, which often 



MENINGITIS. 901 

| assumes a patchy character; to this more or less opaline effusion into 
the subarachnoid tissue soon succeeds ; and presently the corpuscular 
and other solid products of the morbid process begin to accumulate, 
congregating at first more especially on either side of the larger super- 
ficial veins, and following their course, whence they gradually creep 

I over the surface of the convolutions and into the depths of the sulci. 
In some cases of inflammation the yellowish or greenish opaque exuda- 
tion here referred to occupies mainly the prismatic intervals formed be- 
tween contiguous convolutions and the visceral layer of the arachnoid; 

| in some, where it has spread to a greater or less extent over the con- 
vexity of the convolutions the surface of the brain becomes mapped out 
into a series of rounded or irregular congested arese, separated from one 
another by an irregular network of inflammatory exudation; in some 
cases, again, the accumulation is so considerable that the surface is 
uniformly covered with it, and the sulci are widely distended. This 

I exudation, which is often solid, like an ordinary false membrane, occa- 
sionally becomes distinctly purulent. The inflammatory process, which 

i is mainly limited to the substance of the pia mater and to the subarach- 
noid tissue, nevertheless affects to a greater or less extent the neighbor- 
ing arachnoid, on the one hand, and the cortex of the brain upon the 
other. The accumulation in the subarachnoid tissue tends to expel the 
fluid from the arachnoid cavity ; and in cases of extensive inflammation 
this fluid wholly disappears, and the surface of the brain consequently 
becomes more or less sticky and almost dry. The actual appearance 

| in such cases of inflammatory products on the free surface of the arach- 
noid or within its cavity is rare. The intimate connection which sub- 
sists between the vessels of the pia mater and those of the cerebral cor- 
tex renders it almost essential that these should share to a greater or 
# less extent in any process which involves the former. And to a certain 
extent they do thus share : they become dilated and congested, and more 
or less inflammatory change take place in the brain-tissue inclosed 
within their meshes. 

Inflammation may involve any part of the pia mater and spread to 
any extent over it; indeed meningitis, like erysipelas and many other 
forms of inflammation, has a marked tendency to diffuse itself superfi- 
cially. In some cases, however, it occupies mainly the convexity of 
the hemispheres ; in some the base of the brain ; and in some the surface 
of the cerebellum, pons Varolii and medulla oblongata. In the last 
case the inflammation usually extends to a greater or lesser extent along 
the spinal cord. It frequently also, perhaps generally, involves the 
velum interpositum and choroid plexuses ; and, probably, on this account 
the lateral ventricles usually become distended with fluid. Further, it 
often happens in these cases that the ependyma of the ventricles is a 
little rough from the formation of minute granulations on its surface, 
and that at the post-mortem examination the white matter around the 
ventricles is found reduced to a pulp. 

2. Meningitis due to the presence of tubercles nearly always commences 
at the base of the brain, is often limited to the base, and is generally 
most intense there. It differs anatomically from simple meningitis in 
the fact of the presence of gray miliary tubercles, varying from the size 



902 



DISEASES OF THE NERVOUS SYSTEM. 



of a pin's head downwards. These may be so few in number or so 
minute as almost to defy detection they may be so abundant as to 
form large granular clusters, or to blend into irregular, cheesy patches 
of considerable extent and thickness. They commence in connection 
with the walls of the arterioles whose channels they soon obliterate, and 
hence congregate especially along the vessels. They are found mainly 
in the neighborhood of the circle of Willis, extending thence along the 
fissures of Sylvius to the lateral aspects of the hemispheres, around the 
crura cerebri into the great transverse fissure of the brain, and thence 
to the velnm interpositum and choroid plexuses, and also over the pons 
Varolii. They are not, however, limited to these situations. They 
rarely involve the visceral arachnoid, or appear on its free surface; 
they do, however, become developed in greater or less abundance in 
connection with the small vessels of the cortex, so that if the pia mater 
be torn away a greater or smaller number of these vessels with tuber- 
cles in their walls are generally also torn away, together with portions 
of the cortical matter itself. Not unfrequently, indeed, masses of tu- 
bercles at the bottom of the sulci appear to be imbedded in the substance 
of the brain. Minute superficial haemorrhages are not uncommon in 
this condition. When tubercles are few and small, they may sometimes 
be recognized by the finger as minute hard granules, or may be seen 
on holding up detached laminae of pia mater to the light ; or they may 
need the microscope for their discovery. 

3. Spinal meningitis corresponds essentially in all its characters to 
the description which has been given above; and the presence of tuber- 
cles here is not infrequent. They occur especially, Dr. Greenfield tells 
me, over the cervical and lumbar enlargements and on the inner sur- 
face of the dura mater. 

Symptoms and Progress. — 1. Cerebral Meningitis. It is impossible . 
to make any practical clinical distinction between simple and tubercu- 
lar meningitis; we shall include them, therefore, in a common descrip- 
tion. Meningitis, especially when it occurs in children, is said gener- 
ally to be preceded by premonitory symptoms which may vary in their 
duration from a week or two to some months. They are probably, 
however, observed only in cases of tubercular meningitis, and are then 
referable in some degree to the fact that tubercles are already in process 
of development in the meninges, and in some degree perhaps to the 
presence of tubercular formations in other organs, such as the lungs, 
bowels, and serous membranes. These premonitory symptoms are 
variously described, and the majority of them have no distinctive char- 
acters. The child perhaps becomes emaciated, weak and pallid, loses 
his appetite, suffers from constipation, is irritable, fretful, sad, indis- 
posed to play, drowsy in the daytime, and wakeful at night, his sleep 
being attended with startings and grinding of the teeth, and disturbed 
by dreams, from which he wakes up frightened and screaming. He 
may also suffer from more or less febrile disturbance. Amongst other 
occasional premonitory symptoms may be mentioned some of those 
which belong to the earlier stages of the established disease, such 
especially as vertigo, headache, squinting, sickness, and slowness with 
irregularity of pulse. 



MENINGITIS. 



903 



The symptoms of invasion, whether preceded by prodromata or 
coming on without them are exceedingly various. In some cases the 
patient complains of headache across the temples, or through the eyes, 
or elsewhere in the head, which is more or less persistent, but liable to 
paroxysmal exacerbations; in some of vomiting, coming on frequently, 

I without apparent cause and not necessarily attended with marked im- 
pairment of appetite ; in some of fever of irregularly remittent type, 

' attended it may be with more or less severe rigors ; in some of double 
vision. In some cases the first indications of the disease are furnished 

j by more or less dulness, strangeness or wildness of manner, by impair- 
ment of memory or defect of speech, or by the collective symptoms 
which characterize the early stage of delirium tremens. In some cases 
the attack is ushered in with an epileptic seizure. 

The progress of the disease is usually divided into three stages, 

| which in typical cases are for the most part fairly well marked. The 
first stage, which includes the invasion, is generally characterized by 
fever, elevation of temperature, increased rate of pulse, and the phe- 
nomena of nervous irritation ; the second stage is usually attended with 
diminution or cessation of fever, slowness of pulse, or the phenomena 
of commencing paralysis; the third stage, or that of collapse, is the 
stage usually of convulsions and coma, during which also febrile symp- 
toms not unfrequently again manifest themselves and the pulse becomes 
extremely rapid. 

The first stage is ushered in for the most part with various combina- 
tions of the symptoms which have been above enumerated, is generally 
attended with more or less marked elevation of temperature — febrile 
exacerbations, often associated with rigors, coming on irregularly and 
sometimes several times a day; acceleration alternating with slowness 
of pulse ; headache, which is often so severe that the patient screams 
out with pain, or supports his head with his hands, and is not unfre- 
quently associated with more or less tenderness of the scalp and neu- 
ralgic pains in the back of the neck, perhaps extending into the limbs ; 
nausea, and more or less uncontrollable vomiting ; constipation ; dis- 
turbed sleep or sleeplessness; sadness and taciturnity, or querulousness, 
or it may be tendency to delirium. To these symptoms are not unfre- 
quently added hyperesthesia, tremulousness, and muscular debility, 
intolerance of light and sound, hemiopia, illusive appearances, double 
vision, or squinting from spasm of the muscles of the eyeballs, and con- 
tracted pupils. It may be added that in this stage young children are 
generally fretful, peevish, agitated at the approach of strangers, and 
resentful at the attentions of the nurse or mother, and not unfrequently 
even now utter the characteristic hydrocephalic cry. 

In the second stage the patient becomes comparatively quiet, and 
passes into a drowsy condition ; his temperature for the most part falls 
somewhat, and though generally still a degree or two above the normal, 
may sink to that or even below it ; and his pulse becomes slower than 
natural, and at the same time more or less irregular. The transition 
from unrest to rest, and the subsidence of fever give a delusive aspect 
of convalescence. In this stage the cephalalgia, the exaltation of the 
senses of sight, hearing, and touch, the nausea and sickness, and the 



904 



DISEASES OF THE NERVOUS SYSTEM. 



irritability of temper, or sadness, or morosenesSj all subside, and the 
patient becomes apathetic. He sleeps perhaps continuously and is 
roused with difficulty to put out his tongue or take nourishment; he 
probably does not refuse food, but he does not ask for it, nor does he 
trouble himself to restrain his evacuations. His breathing, like his 
pulse, is irregular and characterized by a series of rapid respirations 
followed by long intervals of complete apnoea. It is during this period 
that certain other phenomena are peculiarly apt to be present, to come 
on for the first time, or to undergo aggravation. The hydrocephalic 
cry now becomes, in children especially, a marked feature of the case ; 
it is uttered at frequent but irregular intervals. The following is 
Trousseau's description of it : " He groans from time to time, opens 
his eyes wide, which shine as they do in individuals that are drunk. 
His face, which is usually extremely pale, blushes for a minute or two ; 
then he closes his eyes again, and resumes his former aspect. Gener- 
ally, as he thus opens his eyes, and as his face colors up, the child utters 
a sharp, plaintive cry, which is perfectly characteristic." The face, 
which is usually pale, is liable to sudden temporary flushes, and the 
tache cerebrale is easily produced. Retraction of the abdomen is 
almost always present. During this stage the patient is also apt to 
roll his head from side to side, to move his hands and arms restlessly, 
to wave them or throw them about, to pick at the bed-clothes, or to 
pick his nose, or lips, or ears, or to perform various other movements 
with them ; he may surfer from quiet delirium, or present partial con- 
vulsive movements of his face or limbs; his pupils may become dilated 
or unequal, and irresponsive to light ; sight may fail ; and paralysis 
may come on, especially ptosis, paralytic strabismus, paralysis of the 
portio dura or hypoglossal, or hemiplegia. 

The third stage is characterized by the supervention of convulsions, 
and coma, or of coma alone. The patient who could hitherto be roused 
with more or less ease, now scarcely responds to any external influence. 
He is anaesthetic, deaf, blind, the pupils are dilated, probably unequal, 
and react slowly or not at all to light. Sometimes inflammation or 
ulceration of the cornea takes place. Paralysis has become more pro- 
nounced either in certain muscles or groups of muscles, or on one side 
of the body. He still, however, rolls his head about ; still has sub- 
sultus or tremors, or picks at the bed-clothes, still utters the distressing 
cry peculiar to the disease. The respirations become frequent and ir- 
regular. The pulse may still remain below the normal rate, but more 
usually becomes exceedingly rapid and feeble. The temperature for 
the most part rises, especially in the internal organs ; that is to say 
the limbs become cold and dusky, while the trunk and viscera are burn- 
ing hot. But the temperature during this stage is liable to great variety : 
in one case it rises rapidly as death approaches ; in another it remains 
elevated two, three, or four degrees above the natural standard ; while 
in yet another it falls 10 or 15 degrees or more below it. The cheeks 
are alternately pale and flushed, and the surface bathed in perspiration. 
The tongue, which during the earlier stages may be natural, or may 
present more or less whitish fur upon its surface, in the third stage gen- 
erally becomes thickly coated, dry, and brown, and the teeth get covered 



MENINGITIS. 



905 



with sorcles. Convulsions, as a rule, are now frequent, sometimes in- 

i cessant, sometimes slight, sometimes violent, sometimes limited to the 
face or to the hands, sometimes unilateral, sometimes general. They 
are apt to increase in severity as the fatal end approaches ; and the pa- 
tient, who always dies comatose and sometimes collapsed, is not unfre- 

I quently carried off in a convulsion. 

In addition to the delusive appearance of amendment which charac- 

! terizes the beginning of the second stage, it is not uncommon, towards 
the close of the second or beginning of the third stage, for the patient 

j to wake up as it were from his semi-coma or coma, to recognize his 
friends, and to take an interest in what is going on around him. The 
amendment may last a day or two, and may recur, and is apt not un- 
naturally to raise the hopes both of the friends and of the medical at- 

| tend ant. Unfortunately, however, these hopes are, almost without ex- 
ception, doomed to speedy disappointment, and sooner or later all the 
symptoms recur, become aggravated, and death ends the scene. It is 
nevertheless a fact not only that temporary recovery occasionally takes 
place, but that patients who present distinct symptoms of meningitis 
now and then recover permanently. 

The duration of cases of cerebral meningitis is very uncertain; it is 
generally from one to three weeks, and not unfrequently about a fort- 
night. The different stages also which ha ye been enumerated vary in 
duration, both actually and relatively, and in all cases the transition 
from one to the other is quite gradual. 

It must never be forgotten, however, that although there is a common 
tendency for the progress of meningitis to divide itself into successive 
stages, and although these successive stages have a tendency to assume 
such characters as have been above assigned to them, in a very large 
proportion of cases the symptoms and progress of the disease diverge 
widely from the type. No disease, indeed, is more protean in its fea- 
tures than meningitis, none probably simulates so many other disorders. 
In some cases, as for example when meningitis complicates acute pneu- 
monia, erysipelas, or other inflammatory affections, the only indication 
of what proves to be extensive meningitis may be the supervention of 
drowsiness, coma, and collapse during the day or two preceding death. 
In some cases, indeed, even when the inflammation of the brain is un- 

I complicated, drowsiness and coma are the only symptoms ever recog- 
nized. In many cases the early stage of the disease is mistaken for 

j inebriation or for delirium tremens ; and indeed the symptoms of men- 
ingitis are not unfrequently, during the greater part of its duration, al- 
most exact counterparts of those of delirium tremens. In other cases 
the symptoms have a close resemblance to those of enteric fever, and 

! in children to that vague and uncertain malady which is commonly 

; termed " gastric fever especially to those cases of these affections in 

j which the accustomed diarrhoea is replaced by constipation, and the 
abdomen fails to present its ordinary flatulent distension, while nervous 

I phenomena, such as headache, sleeplessness, irritability, and delirium 
at the same time prevail. In other cases, again, meningitis presents 
many of the features of general tuberculosis ; but, indeed, here it must 
be recollected that general tuberculosis is specially apt to be attended 



906 



DISEASES OF THE NERVOUS SYSTEM. 



with involvement of the surface of the brain, and that hence the super- 
vention of meningitis in the course of the general disease should not 
be overlooked. Sometimes the patient, from the commencement of his 
malady up to the occurrence of coma, is in a condition of mild de- 
lirium ; occasionally, but much more rarely, he is in a state of mani- 
acal excitement ; sometimes epileptic convulsions predominate ; some- 
times he is sensible from first to last. In some instances headache and 
vomiting never present themselves ; in some distinct paralysis never 
occurs ; in some paralytic phenomena form the most striking features 
of the malady. The hydrocephalic cry may never be uttered. 

Still, however obscure the case may be, there is almost always some- 
thing during its progress which reveals to the observant practitioner 
its fatal character. The cloven hoof shows itself. There is vomiting 
without obvious cause, or fever of a certain character, or retraction of 
the head, or hyperesthesia ; or there is some affection of the pupils, or 
some temporary or permanent paralysis, even though it be limited to 
the levator palpebrse or one of the recti muscles of one eye ; or there 
is some convulsive movement, or the characteristic distressful cry, or 
some special change in the mental condition ; or the respirations are 
characteristically irregular ; or the muscular debility and tremulous- 
ness are out of all proportion to the other symptoms exhibited. Fur- 
ther, optic neuritis is frequently present, even from the earliest period 
of the patient's illness, and generally also Trousseau's tache c6rebrale, 
a phenomenon, however, of secondary importance, can be readily devel- 
oped. It consists in the ready appearance and long duration of a com- 
paratively wide blush of redness in the course of a line made by draw- 
ing the finger-nail or the point of a pencil along the skin, more 
especially on the face, abdomen, or inner aspect of the thigh. It need 
scarcely be added that, since the larger number of cases of meningitis 
are of tubercular origin, accuracy of diagnosis may in many cases be 
insured by careful attention to the history of the patient and by care- 
ful examination of his lungs and other organs in reference to the pres- 
ence of tubercular disease in them. Occasionally tubercular deposits 
may be recognized in the choroid. 

The great variableness of the phenomena which attend meningitis 
becomes easy of explanation when we look to the morbid anatomy of 
the disease and consider how many parts are liable to be involved, and 
in what unequal degrees. We have seen that the morbid process, 
especially if it be of tubercular origin, is peculiarly apt to invade 
the cortical substance of the brain. What wonder, therefore, that 
mental phenomena and convulsions should ensue, and that these should 
vary largely in their details in different cases? We have seen how 
almost invariably the base of the brain suffers more than other parts, 
and how the nerves are consequently liable to be surrounded by, and 
involved in, the inflammatory process. What wonder that hyperes- 
thesia and paralysis, variable as to their seat and degree, should be 
present ? We have seen that the lateral ventricles are apt to become 
distended with fluid, their parietes softened and compressed. Is it 
remarkable that, when these changes take place, coma and paralysis 
are of common occurrence ? 



MENINGITIS. 



907 



2. Spinal Meningitis. — The symptoms of acute inflammation of the 
spinal pia mater differ but little from those which have been ascribed 
to inflammation of the theca vertebralis, and necessarily have some 
resemblance to those which become developed during the course of 
myelitis. Indeed, many of the symptoms which occur in inflamma- 
tion of the dura mater are really due to the extension of disease to the 
pia mater, and many of those of inflammation of the pia mater are 
essentially referable to involvement of the subjacent nervous matter. 

When any considerable length of the pia mater is affected, more or 
less fever of a remittent character, and possibly attended with rigors, 
will probably be present. There will probably also be anorexia and 
thirst, and abnormal rapidity of pulse. Sometimes, however, the pulse 
is slow. The patient most likely complains of pain in the course of 
the spine, not much increased by simple pressure, but greatly aggra- 
vated and sometimes amounting to unendurable agony when either 
muscular movements are performed or the spinal column is bent or 
twisted. There is generally more or less rigidity of the voluntary 
muscles — the muscles of the back, and more especially those of the 
neck, being chiefly affected, and the head consequently more or less 
powerfully retracted ; the elbows are apt to be a little separated from 
the body, and the forearms and hands somewhat flexed ; the lower 
extremities are probably similarly affected ; the jaws are often firmly 
closed, and the muscles of the face contracted so as to give to the ex- 
pression the well-known risus sardonicus. Further, sudden twitches 
and spasms of a tetanic character are apt to occur from time to time, 
not only in the muscles of the back, which becomes consequently a 
little more arched, but in those of the limbs and head and neck. At 
the same time the patient complains of more or less severe pain, not 
merely in the back, but also in the head, and especially in the extremi- 
ties, into which it shoots in sudden paroxysms, which are excited when- 
ever he executes any movement, or his muscles are forcibly disturbed 
by the hands of the attendant. There is not unfrequently also some 
hyperesthesia. 

Partly mingled with these phenomena, but more especially super- 
vening upon them, is impairment of voluntary movement and of sen- 
sation, the patient loses more and more the power over those limbs 
which correspond to or are below the seat of lesion, and he loses also, 
to a greater or less degree, control over the rectum and bladder. In- 
deed, incontinence of urine and of faeces is apt to take place even when 
the paralysis of the voluntary muscles is very slight, and while at the 
same time the patient's mental faculties appear to be intact. More or 
less tingling, formication, or numbness, is not unfrequently present. 
If the disease involve the higher part of the spinal pia mater and that 
of the medulla, difficulty of respiration, speech, deglutition, and mas- 
tication may be present. Priapism and increased irritability of the 
excito-motor functions are rarely observed. Vertigo, headache, slight 
delirium, and other cerebral phenomena generally arise in the course of 
the malady, and more especially if the meningitis extend from the 
spine to the base of the brain. 

The main features of the disease appear to be pain, more or less 



908 



DISEASES OF THE NERVOUS SYSTEM. 



intense, along the spine, and shooting thence into the extremities, 
especially aggravated by movement; hyperesthesia ; rigidity with 
occasional spasmodic contraction of the voluntary muscles ; and more 
or less want of power over the rectum and bladder. Absolute paralysis 
is rare, and absolute anaesthesia still less common. Indeed the patient, 
who has probably been for some days confined to his bed, apparently 
unable to move, and suffering agony when involuntary or other move- 
ments are effected, and, further, exerting no control whatever over his 
evacuations, will sometimes suddenly, in his restlessness, agony, or 
delirium, sit up in bed, or even get out of bed and pace the room. 

The commencement of the disease, especially if it be secondary to 
any other serious malady, is often insidious and obscure. And even 
when it is of purely idiopathic origin, the symptoms may be so slightly 
pronounced during the first three or four days that the patient refuses 
to go to bed, and in some cases goes on with his usual avocations. 
The initial symptoms are not unfrequently more or less pain, usually 
supposed to be rheumatic, in the course of the spine and of the nerves 
which are given off from it, increased by movement, and attended 
with febrile disturbance, restlessness, irritability of temper, and sleep- 
lessness. 

Spinal meningitis is a very fatal malady, and although doubtless 
some persons recover from it, the great majority die, succumbing for 
the most part between the third or fourth day and the third or fourth 
week. Most deaths, however, occur within the week, and are due 
either to asphyxia or to asthenia, promoted as this latter often is by the 
rapid supervention of bedsores or other complications. 

Treatment. — Cerebral meningitis for the most part defies all medical 
treatment ; still, as recovery certainly takes place occasionally, even 
when it is of a tubercular origin, it behooves us to give some care to 
the management of all cases of the kind that come under our charge. 
The patient should be placed in a room sufficiently darkened to be 
grateful to his irritable eyesight, sufficiently quiet to prevent all audi- 
tory disturbance, and at the same time cool and well ventilated. He 
should be carefully watched by a quiet and judicious attendant. 
Everything, indeed, should be done to avoid the infliction of discomfort 
on the hyperaesthetic senses, to calm irritability, and to promote rest. 
If the limbs be cold, they should be kept at an equable temperature by 
means of flannel or other warm clothing. The headache which is so 
often present may be relieved by the temporary application of evapor- 
ating lotions, or of ice to the forehead or shaven scalp ; and it may 
even for the same and other purposes be advisable to apply leeches 
behind the ear, or blisters or other counter-irritants to the temples, 
scalp, or back of the neck. Leeches, however, should only be applied 
early in the course of the disease. The number to be employed, and 
the amount of blood to be removed, must be determined partly by the 
age of the patient, partly by the other circumstances of the case. 
Thus, if the meningitis occur in a healthy-looking adult, a free re- 
moval of blood even by venesection will be well borne, and may be 
highly beneficial. In a young child two or three leeches are generally 
ample. The relief of head symptoms will often be attended with alle- 



MENINGITIS. 



909 



viation of sickness. But this may sometimes be treated directly with 
advantage by the administration of either ice, bismuth, hydrocyanic 
acid, oxalate of cerium, or other of the remedies which are ordinarily 
given to assuage this condition. It is generally highly important to 
keep the bowels freely open, and this is sometimes (in consequence of 
the extreme obstinacy of the constipation) exceedingly difficult to effect. 
Enemata may be employed ; but it is generally better to give purga- 
tives by the mouth, and especially to give those which are not likely 
to upset the stomach. Sir T. Watson recommends as the best purga- 
tives for children calomel and jalap, or calomel and scammony. 
Castor oil also generally agrees well with children. In the case of 
adults purgation should be actively employed. Amongst special reme- 
dies, may be enumerated : first, simple saline or febrifuge medicines, 
which have doubtless little efficacy ; and second, iodide of potassium, 
which is probably advocated rather on theoretical grounds than from 
actual experience of its value. Opium is generally considered to be 
contraindicated ; we must confess, however, that we have not unfre- 
qu entry administered it during the earlier stages of meningitis, not 
only with no obvious injury to the patient, but with manifest relief to 
his irritability and insomnia. It must be added that fluid nutriment 
should, as far as possible, be administered in small quantities, at fre- 
quent intervals. 

Prophylactic measures are of paramount importance in the case of 
either children or adults in whom there is reason to fear the superven- 
tion of meningitis. Their studies or other mental labors should be 
intermitted; they should be kept quiet, both in mind and body, should 
keep early hours, be removed (if need be) to some healthy locality, 
occupy well-ventilated rooms, have ample wholesome nourishment, and 
be placed under a course of cod-liver oil and tonics; and, further, all 
their functional disturbances should have due attention paid to them; 
sickness should be obviated, constipation overcome. 

It is scarcely necessary to add that adults may as a rule be treated 
far more actively than children, and those who are non-tubercular far 
more actively than those who are tubercular ; and that for such patients 
the main remedies during the attack consist in cold to the head, 
leeching behind the ears, and active purgation. 

As regards the treatment of spinal meningitis, it is essential that the 
patient should be kept in the recumbent posture on a suitable bed, that 
he should be kept scrupulously clean and dry, that all parts liable to 
bedsores should be defended from the effects of pressure, and that the 
condition of his bladder and bowels should be carefully watched, and 
the bladder, if necessary, relieved periodically by the use of the catheter. 
In other respects the remedial measures to be employed are the same 
as those which are supposed to be serviceable in cerebral meningitis. 



910 



DISEASES OF THE NERVOUS SYSTEM. 



ENCEPHALITIS AND MYELITIS. 

Inflammation and Suppuration of the Substance of the Brain and Cord. 

Causation. — The circumstances which determine the occurrence of 
acute inflammation in the brain and cord are, like those which cause 
inflammation elsewhere, very various. In most cases it is due to the 
extension of inflammation from without; to extension of inflammation 
directly from the pia mater, or in those cases in which pus is extrava- 
sated into the arachnoid cavity to extension from that cavity; or it 
follows upon inflammation originating in the dura mater or the bones 
of the skull or spine, or is referable to the direct spread in depth of 
erysipelatous and other like affections of the skin and subjacent tissues. 
In a large number of cases encephalitis or myelitis arises from the | 
influence of some irritating foreign body, such as a clot, or tumor, or 
parasite, or mass of softening situated within the nervous substance or 
implicating it from without. It is a common consequence of injuries, 
even if these be unattended with fracture. It is sometimes referable 
to pyaemia. And occasionally it seems to be an idiopathic affection, 
arising under the influence of exposure or from causes which we fail to 
recognize. 

Morbid Anatomy. — 1. Encephalitis. There is no reason to doubt 
that inflammation occasionally involves the great bulk of the brain, as 
it certainly sometimes does the whole thickness of the cord in no in- 
considerable portion of its length. The cases, however, in which this 
phenomenon has been observed are cases in which the substance of the 
brain has been found after death generally much congested and softened, 
and in which the inflammatory process, assuming it to have been pres- 
ent, must have been in quite its initial stage. The condition, in fact, 
has differed little from what is seen in general congestion of the organ, 
as it may sometimes be observed in fatal cases of epilepsy, delirium 
tremens, or sunstroke. In most cases of encephalitis the inflammation 
is limited in its extent, occupying sometimes portions of the gray matter, 
sometimes portions of the white, and sometimes both of these indiffer- 
ently. In some cases a single patch is present, in some there are several ; 
and their sizes and forms vary within wide limits. If, however, not 
determined as to their shape and extent by the fact of being secondary 
to some clot or other adventitious mass, or to meningeal inflammation, 
they tend to assume a roundish or ovoid form, rendered more or less 
irregular by the configuration of the surface of the brain and the arrange- 
ment of its parts. The changes which accompany and mark the early 
stage of acute inflammation are more or less circumscribed congestion, 
effusion of fluid and other inflammatory exudation, and softening. The 
tissues of the affected part are swollen and pulpy, and generally admit 
of being readily washed away under the impulse of a stream of water, 
leaving a shreddy excavation behind. The redness is more or less intense 
according to the quantitative relation which the congested vessels have 
to the amount of exudation, and is generally patchy. Sometimes small 
extravasations of blood occur. Further, more or less congestion and 



I 



ENCEPHALITIS — MYELITIS. 



911 



oedema, together with some yellowness of tint, may generally be ob- 
served in the surrounding tissues. 

With the progress of the inflammatory process, inflammatory cor- 
puscles or pus-cells accumulate in the inflamed district, which gradu- 
ally loses its congested aspect, becomes yellowish or greenish, and less 
and less consistent. Presently the central portion becomes diffluent, 
and an abscess is formed, the pus of which is thick, glairy, yellowish 
or greenish, and occasionally offensive, and the parietes of which are 
constituted by the still solid but soft and breaking-down tissue. Occa- 
sionally the abscess becomes encysted, the capsule attaining sometimes 
the thickness of a quarter of an inch. The microscopical characters 
presented by the inflamed patches vary somewhat according to the 
stage at which the process has arrived. In the earlier periods there 
may be observed, besides vascular changes with accumulation of leuco- 
cytes in the perivascular sheaths, more or less destruction of the nervous 
elements — the myelin of the nerve-tubules breaking up into globules 
of various sizes — together with a greater or less development of granule- 
cells. Somewhat later, the degenerating tissue becomes loaded with 
pus-corpuscles. In the fully-formed abscesses, the puriform matter is 
not unfrequently found void of pus or other cells, and comprising only 
fatty matter and the debris of the tissues. 

Abscesses of the brain are not of very frequent occurrence, and are 
mostly solitary. When multiple, they are almost invariably pysemic. 
The abscesses of most interest to the physician are those which are 
secondary to disease of the ear, or to disease affecting the nose, the 
orbits, or other parts of the skull. When secondary to ear-disease, they 
occur either in the adjoining part of the middle cerebral lobe, or the 
adjoining part of the posterior lobe, or in the corresponding lateral 
lobe of the cerebellum, or somewhat more rarely in the pons Varolii. 
In most instances the surface of the bone is carious, the dura mater 
over it is softened and inflamed, and the abscess is situated in a dis- 
eased patch of brain, which has become adherent; but occasionally the 
bone and the dura mater over it appear to be healthy, and the abscess 
in relation with them is separated from the surface by a layer of 
healthy-looking brain-substance. The explanation of this fact is not 
easy ; but it is generally assumed to be due to the plugging up of, or 
to the extension of inflammation along, some of the vessels passing 
from the sinuses into the substance of the brain. According to Sir W. 
GulPs and Dr. Sutton's statistics, it appears that abscesses occur equally 
on both sides of the brain ; and that, although any part may be their 
seat, they are most common in the middle cerebral lobe. The presence 
of an abscess of medium or large size in the substance of the brain 
causes more or less general enlargement of the lobe or part within 
which it is seated, with flattening of the surface of the brain over it 
and in its vicinity, obliteration of the sulci, and displacement of sub- 
arachnoid fluid. An occasional result of the presence of an abscess is 
its extension, by bursting or by gradual erosion, into the cavity of the 
arachnoid, or into one of the ventricles, or its discharge externally 
through the ear or nose. 

2. Myelitis. — Inflammation of the substance of the cord is attended 



912 



DISEASES OF THE NERVOUS SYSTEM. 



with similar changes to those above described in connection with the 
brain. When secondary to disease of the membranes it first involves 
the white substance, and only subsequently, and at a comparatively 
late period, extends to the central gray matter. Idiopathic inflamma- 
tion, however, mostly affects primarily and principally the central gray ! 
matter. It results in softening of the nervous tissues, with a much j 
more marked tendency to the extravasation of blood than attends cere- 
bral softening ; indeed, in Charcot's opinion, haemorrhage (however 
copious) into the substance of the cord is mostly, if not always, the 
result of previous inflammatory softening. Inflammation generally 
tends to implicate the whole thickness of the cord, and though fre- 
quently limited to comparatively short lengths of it, not very un- 
commonly involves extensive tracts. Actual abscesses are of rare 
occurrence. We may add that patients occasionally die with symp- 
toms of rapidly-developed paraplegia, pointing to extensive disorgani- 
zation of the cord, in whom post mortem little or no obvious change 
in the texture of the cord can be detected. It is not improbable that 
in. some, at any rate, of these cases the patient has been really suffer- 
ing from inflammation in the earliest stage. 

Symptoms and Progress. — 1. Encephalitis. The symptoms which 
may be referred to inflammation of the substance of the brain no 
doubt extend over a wide range. Indeed, it is unquestionable, as has 
been already pointed out, that many of the symptoms of cerebral men- 
ingitis are really due to implication of the subjacent gray matter. 
Further, these conditions are so generally combined that it would be a 
mere w r aste of space and of ingenuity to endeavor to make any abso- 
lute distinction between them. 

Of acute general inflammation of the encephalon, there is little to 
be said. The cases are rare, the symptoms which they present are 
vague, and the morbid changes which are observed after death are, 
to say the least, obscure. They are mostly of rapid progress, and 
attended, as Dr. Wilks observes, with more or less severe pyrexia, 
delirium, dulness of intellect, and final coma, but perhaps no other 
symptoms especially referable to the brain. Occasionally there is a 
preliminary stage in which, as he says, the patient may suffer from 
headache, sickness, slow pulse, and constipation. It need scarcely be 
observed that these are symptoms which are not unfrequently met 
with in cases of sunstroke, and occasionally in persons who have been 
indulging continuously, for some days or weeks, in excessive drinking. 

The symptoms which attend inflammation secondary to the pres- 
ence of apoplectic clots, tracts of softening, tumors, and the like, are 
also exceedingly vague. A little accession of fever, a little increase 
of headache or giddiness, a little failure of appetite, a little increase 
in the paralytic phenomena from which the patient has been suffer- 
ing, a little impairment of intelligence, the occurrence of delirium, 
or of convulsions, or of coma, and perhaps the development of some 
rigidity in the affected limbs, or some hyperesthesia, or some pain in 
muscles or joints, or some tendency to the formation of a bedsore on 
the affected side, separately or in combination, are the main indications 
of the supervention of inflammation. 



ENCEPHALITIS MYELTTIS. 913 

The symptoms due to localized patches of inflammatory softening, 
or of suppuration, in the substance of the brain are not less vague and 
obscure than those which belong to the varieties of inflammation which 
have been above considered. Among those which may be present are 
febrile disturbance with rigors, vomiting and constipation, vertigo, 
headache often occurring mainly at one spot, dulness, stupidity, de- 
lirium, coma, epileptiform convulsions, paralysis, affection of speech 
or of the special senses, and want of control over the bladder and 
rectum. In addition, few if any of the other symptoms which may 
be observed in cerebral meningitis may not at one time or another, or 
in certain cases, be present in these. On the other hand, an abscess, 
may be found encysted in some part of the brain-substance, which has 
existed for weeks or months, possibly years, without giving any hint 
of its presence. It is obvious, indeed, when we consider the various 
sizes which abscesses present, the various positions which they may 
occupy in the substance of the encephalon, and the various lesions 
(pyaemia, disease of the ear, and inflammation of the dura mater or 
pia mater, or both) with which they are apt to be associated, that 
the symptoms which accompany them must present the greatest pos- 
sible variety. Thus, as regards febrile symptoms, there can be little 
doubt that the inflammatory process in the brain will usually be at- 
tended with more or less marked fever, and not improbably with rigors, 
but that these phenomena will certainly be aggravated if pyaemia be 
present, or if suppuration be taking place beneath the dura mater, or 
pus have escaped thence into the cavity of the archnoid ; while, on 
the other hand, they may be entirely absent if the patch of inflam- 
mation be small, or if it pass into the chronic state, or form an encysted 
abscess. Again, pain is one of the most common symptoms of abscess 
of the brain : pain various in character, often referred to a particular 
spot, sometimes affecting the eyes, or shooting through the temples, 
or occupying the back of the head ; but pain may be absent from first 
to last, and generally, when it is present in any marked degree, is due 
rather to coexistent affection of the bones or dura mater than to 
cerebral disease itself. Another frequent consequence of abscess in 
the brain is paralysis, or interference with the functions of one or 
other of the nerves of special or common sensation. But while it 
will be admitted that a large abscess may cause hemiplegia on the 
opposite side of the body, it is obvious that the presence of hemiplegia, 
and especially of affection of any one nerve, or group of nerves, will 
depend less on the size of the abscess than on the situation which it 
occupies. If the abscess be seated in the pons Varolii or medulla ob- 
longata, a wide extent of paralytic affections of the spinal nerves will 
almost necessarily ensue, and respiration and deglutition be largely inter- 
fered with. The evidences of optic neuritis may be observed in many 
of these cases, as well as in connection with inflammatory affections of 
the membranes. 

There are, indeed, no special symptoms or groups of symptoms the 
presence or absence of which will enable us to diagnose the presence 
or absence of a patch of inflammatory softening or of an abscess in the 
brain. We have, however, good reason for suspecting the presence of 

58 



914 



DISEASES OF THE NERVOUS SYSTEM. 



such lesions when such symptoms as have been above enumerated 
supervene in the course of chronic otorrhcea, or of syphilitic or other 
forms of caries or necrosis of the bones of the skull, or upon injuries to 
the skull or brain. Yet, even in such cases as these, the symptoms \ 
which we take to be indicative of cerebral abscess may be due to sup- 
puration beneath the dura mater, with extension to the arachnoid or ; 
to the pia mater. 

The onset of the symptoms referable to abscess is sometimes marked 
by a sudden attack of convulsions, sometimes by unilateral or more 
circumscribed loss of power or sensation, sometimes by cephalalgia 
with vertigo and vomiting, sometimes by impairment of intelligence, 
and sometimes by fever. The pulse, as in other cerebral affections, is 
not unfrequently slow and irregular. The progress of the disease, like 
that of meningitis, may often be divided into a stage of irritation and 
one marked by the impairment or abeyance of the functions of the 
nervous centres, and passing into collapse. In the former we may ob- 
serve vertigo, headache, intolerance of light, hyperesthesia, more or 
less irritability, wakefulness, and perhaps delirium and vomiting; in 
the latter, disappearance of pain, paralysis, want of control over the 
action of the bladder and rectum, drowsiness, stupor, coma. Convul- 
sions may occur at any time; but, we repeat, the symptoms are varia- 
ble in the highest degree, both as to their nature and the order of their 
succession ; many who have abscess in the brain die without the pres- 
ence of abscess having ever been suspected ; and many cases in which 
we venture upon the prediction that abscesses will be discovered, falsify 
our prediction upon the post-mortem table. Reckoning the duration 
of these cases from the time when acute symptoms indicative of brain- 
disease first manifest themselves, they may be said to prove fatal usually 
from the fifth or sixth day up to the end of the third or fourth week. 
Death is commonly preceded by coma, but is sometimes due to asthenia 
and sometimes to asphyxia. 

2. Myelitis. — The symptoms of acute myelitis are, in the main, those 
of suddenly occurring paraplegia, and are therefore in many respects 
like those referable to spinal meningitis. They have a closer resem- | 
blance, however, to those which follow upon fracture of the spine at- 
tended with injury to the cord. In considering the symptoms due to i 
myelitis there are two or three considerations which it is important to 
bear in mind. In the idiopathic affection the inflammation affects 
primarily, and in the highest degree, the central gray matter of the 
cord; hence; it follows that sensation will probably be at least as soon 
and as profoundly involved as motion. In meningitis, and other dis- 
eases affecting the cord from without, the white matter is mainly im- 
plicated, and motion is lost in far higher proportion than sensation. 
In myelitis there is a great tendency for the disease to diffuse itself 
throughout the length of the cord, and thus not merely to cause grad- 
ually ascending paralytic phenomena, but also to annul the reflex func- j 
tions of the cord and the electrical contractility of a gradually increasing 
number of muscles. The result is different, as we know, when para- 
plegia follows any limited lesion of the thickness of the cord. In 
myelitis the profound involvement of the elements of the gray mat- j 



ENCEPHALITIS MYELITIS. 915 

| ter naturally tends rapidly to induce the peripheral nutritive conse- 
i quences of spinal lesions, especially wasting of muscles, the develop- 
ment of bedsores on the sacrum and elsewhere, and inflammation of 
the bladder and kidneys. Idiopathic myelitis in this respect indeed 
far more resembles the effects of serious accidental injuries to the spine 
and cord than any other form of disease. Further, the gray matter 
of the cord is, so far as we know, insensible to pain, and lesions which 
! directly involve it are also unattended with pain. Myelitis is not, 
! therefore, usually a painful disorder ; pain, indeed, in spinal affections 
j is almost always the consequence of pressure upon, or involvement of, 
the sensory nerves within the spinal canal, or of the posterior roots in 
| their passage through the white matter of the cord. Hence pain in 
the back, and extending thence to the trunk or to the extremities, is 
i much less likely to be due to myelitis than to meningitis, and, it may 
( be added, less likely to be due to meningitis than to the growth of 
tumors or the extension of aneurisms. Lastly, twitchings and tetanic 
spasms of the muscles are in no sense an indication of myelitis. They 
are common, however, in meningitis. 

The symptoms of acute myelitis sometimes come on gradually in the 
course of a few days, sometimes manifest themselves with sudden in- 
tensity. A patient, perhaps after long-continued over-exertion, or 
after exposure to the weather, or sleeping on the damp grass, is at- 
tacked in his toes and feet with numbness and tingling, which gradu- 
ally extend upwards, and are succeeded after a varying interval by the 
progressive or almost sudden annihilation of sensation and of volun- 
tary motion in the lower extremities, and up to the level of a horizon- 
tal line which corresponds to the upper limit of the distribution of the 
involved spinal nerves. The relative dates at which sensation and 
voluntary motion are lost vary in different cases, as also does the de- 
gree in which the corresponding limbs are involved. Nor does it 
necessarily follow that either sensation or motion should be wholly 
abolished. There is not usually absolute pain, still less pain of a 
neuralgic character ; but there is often a more or less distressing sense 
of restlessness and tingling in the paralyzed limbs, and of constriction 
round the abdomen and the chest. There may, however, be some 
cutaneous hyperesthesia at the upper limit of the affected region. 
Twitchings of the paralyzed muscles may attend the earlier stages of 
paralysis ; but generally these soon cease, and the directly implicated 
muscles, as a rule, speedily lose their contractility to Faradization, and 
become flaccid and lifeless. The muscles, however, which become thus 
affected are only those supplied by the diseased length of cord ; they 
are hence few or many, according to circumstances ; while all those 
which are supplied by nerves given off lower down retain this and 
their reflex excitability and their bulk, as in ordinary cases of para- 
plegia. Priapism is occasionally present ; the bowels are constipated, 
and the motions discharged unconsciously ; and there is either reten- 
tion or incontinence of urine. Bedsores, especially over the sacrum, 
are apt to arise, in spite of every precaution, sometimes within four or 
five days of the commencement of paraplegia ; and at the same time, 



916 



DISEASES OP THE NERVOUS SYSTEM. 



even where the greatest care has been taken, the urine probably be- 
comes ammoniacal and the mucous membrane of the urinary tract 
inflamed. 

It need scarcely be added that the distribution and extent of the 
paralytic phenomena will be determined by the position and extent of 
the disease; that there will be involvement of the lower limbs only 
when the disease occupies the mid-dorsal region ; of the upper and 
lower extremities when the cervical enlargement is included; hemi- 
paraplegia when one side of the cord mainly suffers; difficulty of res- 
piration when the intercostal nerves are implicated ; apnoea when the 
origins of the phrenic nerves are also involved. In the last two cases 
difficulty of speech and inability to discharge accumulating mucus from 
the bronchial tubes add seriously to the patient's sufferings. 

It must not be forgotten that, although cerebral symptoms, and 
neuralgic pains, and spasmodic movements of the muscles are no nec- 
essary part of myelitis, they are not uncommonly superadded in con- 
sequence of the coexistence of some degree of meningeal inflammation 
and brain implication. Neither must it be forgotten that more or less 
marked fever is often present, which may be attended with remissions, 
rigors, and more or less profuse perspiration. 

Acute myelitis is a very grave disorder, and generally terminates 
fatally in the course of a few days or a few weeks. In the less severe 
or less extensive cases, however, life may be prolonged for an indefinite 
period with persistence of paraplegic symptoms ; or the patient may 
recover in some degree, and in rare cases undergo perfect restoration to 
health. The cause of death varies. Death, however, is frequently due 
to asthenia, which may be largely determined by the secondary affec- 
tions of the skin and urinary passages ; or to apnoea referable to im- 
plication of the respiratory nerves. 

Treatment. — For the treatment of inflammation of the substance of ! 
the brain little or nothing can be done directly. We may, if the 
symptoms be severe and their onset sudden, have recourse to the clas- j 
sical measures : namely, cold to the head in the form of evaporating 
lotions, affusion, or the ice-bag ; purgation by means of active drugs, 
and especially of such as cause watery evacuations ; and the abstraction j 
of blood, preferably by leeches, from the temples or behind the ears, 
or by cupping at the nape of the neck. It must be admitted, how- 
ever, that these measures are not often of any obvious utility. For the 
most part, however, the same general treatment may be employed here i 
as has been already suggested for meningitis. If, however, the affec- 
tion be traceable to inflammation of the ear, or disease of the bones of 
other parts of the skull, the question of surgical interference will 
naturally arise. 

For the treatment of myelitis we must also refer to remarks which 
have been previously made under the head of spinal meningitis. 



SCLEROSIS. 



917 



SCLEROSIS. (Chronic Inflammation.) 

The affections which we are about to consider under the above 
heading form a very interesting clinical group, which has been mainly 
investigated and unravelled by the labors of Duchenne, Vulpian, and 
Charcot in France, by Todd, Gull, and Lockhart Clarke in our own 
country, by Brown-Sequard, and in a greater or less degree by various 
other physicians both here and abroad. They are probably all of in- 
flammatory origin ; but the inflammation to whose effects they are due 
is, like cirrhotic inflammation of the liver, marked, for the most part, 
by a slow development of adventitious fibroid tissue attended with the 
gradual wasting and degeneration of the essential elements. In some 
instances, according to Charcot, the inflammatory process begins in the 
nerve-cells, in which case it may either continue strictly limited to 
them, or gradually involve the surrounding connective tissue to a 
greater or less extent. 

In the majority of cases the first indication of disease would seem to 
consist in an overgrowth or hyperplasia of the neuroglia, indicated by 
the appearance in it, and in the perivascular spaces, of a greater or less 
abundance of the cells characteristic of embryonic tissue, together with 
a greater or less increase of the amorphous intercellular substance, 
which takes part in the constitution of the neuroglia. At this stage 
the affected tracts of tissue are somewhat swollen, but their nervous 
elements present little, if any, evidence of disease. As the morbid pro- 
cess, however, advances, the hypertrophied neuroglia contracts and 
hardens, its newly-formed cells get small and indistinct, the originally 
amorphous matrix assumes a delicate fibrillated character, and the 
bloodvessels become thick-walled and their channels narrowed. The 
nerve-tubules and nerve-cells, moreover, which are situated in the dis- 
eased regions, now undergo important changes. When the sclerosis is 
situated in the white substance of the cord or brain, the nerve-tubules 
are seen to be more widely separated from one another than natural, 
the width of the intervals between them depending of course on the 
quantity of adventitious matter which has accumulated there. The 
tubules for the most part diminish in thickness, mainly in consequence 
of the partial disappearance of the white substance of Schwann, and 
sometimes become moniliform ; but intermingled with such tubules 
others may generally be observed which are either of normal thickness 
or are actually increased in diameter from swelling of the axis-cylinder. 
In the most advanced conditions of disease the nerve-tubules are greatly 
atrophied, and in many instances wholly deprived of their myeline 
sheaths ; but they are rarely, if ever, absolutely destroyed. When the 
sclerosis occupies the gray matter, as, for example, the anterior cornua 
of the cord, we find, in addition to atrophy of the nerve-tubules, cor- 
responding changes in the nerve-cells. In some cases, as Charcot 
points out, they become swollen, and, it may be, enormously enlarged, 
faintly granular and opalescent ; and at the same time their processes 
appear more or less thickened and twisted. These changes, which he 
ascribes to irritation, mainly characterize the early period of the dis- 



918 



DISEASES OF THE NERVOUS SYSTEM. 



ease. Much more commonly the changes observed are of an atrophic 
character. In some cases the cells become pigmented, diminish in size, 
and assume a more or less globular form, their processes at the same 
time becoming attenuated and shortened ; and after awhile they become 
reduced to simple roundish accumulations of pigment, and finally per- 
haps wholly dissipated. In other cases no pigmental deposit takes 
place, but the cells shrink in all their dimensions, each one drying up, 
as it were, into a kind of mummy. The processes partake in this 
change, and disappear in a greater or less degree. It may be added 
that Lockhart Clarke has described as sometimes present in tracts of 
sclerosis irregular patches of disintegration, from which all traces of the 
normal elements of the part, whether neuroglia, bloodvessels, nerve- 
tubules, or nerve-cells, have disappeared. 

Sclerotic change is indicated, as to its coarser features, by a more or 
less grayish translucent aspect of the affected part, with induration, and, 
according to the length of time in which it has been in progress, either 
some tumefaction, or a greater or less degree of contraction. Further, 
there is usually close adhesion of the surface of the affected part to the 
pia mater over it, and more or less equivalent change in the pia mater 
itself. In the great majority of cases death occurs at an advanced 
period of the disease, and hence induration and diminution of bulk are 
generally observed. 

Sclerosis has a remarkable tendency to be limited in different cases 
to certain tracts or certain regions of the nervous centres, and compar- 
atively rarely transgresses these limits. Thus certain cases (infantile 
and adult spinal paralysis, general spinal paralysis, and progressive 
muscular atrophy) are characterized by the limitation of the sclerosis to 
the anterior cornua of the gray matter of the cord, or more exactly (in 
many cases) to the groups of large nerve-cells therein situated — in- 
volving these parts, it may be, in their entire longitudinal extent, and 
rarely extending horizontally beyond them ; other cases (lateral sclero- 
sis) are distinguished by the fact that the sclerotic change has its special 
seat in the lateral white columns, which are then usually symmetri- 
cally affected in a considerable part of their length ; other cases, again 
(locomotor ataxy) are peculiar in the fact that the sclerosis involves 
mainly and often exclusively the posterior white columns, or rather 
perhaps the outer band of these columns, the fasciculi of Goll in many 
cases escaping ; in other cases (glosso-labio-laryngeal palsy) the motor 
nuclei of the medulla oblongata are the special seat of disease ; while 
in yet others (disseminated sclerosis) the sclerotic change is scattered 
irregularly in patches throughout the nervous centres — brain and cord. 

Infantile Spinal Paralysis. (Infantile Paralysis.) 

Definition. — By these terms, as also by that of " essential paralysis," 
is known a peculiar paralytic affection coming on in young children, 
with acute symptoms, and for the most part with fever, and ending 
speedily in permanent paralysis and rapid atrophy of certain muscles 
or groups of muscles. 

Causation. — Infantile paralysis may, according to the statistics of 



INFANTILE SPINAL PARALYSIS. 



919 



M. Duchenne (fils), come on at any time from birth up to ten years of 
age ; but the great majority of cases occur during the second year of 
life. Its causes are obscure ; it seems, however, neither to be heredi- 
tary nor to be dependent in any degree on privation or other conditions 
associated with poverty. Dentition would appear to be largely con- 
cerned in its causation, and it has often been observed to follow on 
measles, " gastric fever," and other febrile maladies. Exposure to cold 
and damp is undoubtedly a common cause of the disease. 

Morbid Anatomy. — The morbid processes of infantile paralysis con- 
cern the spinal cord, the motor nerves, and the organs of locomotion. 
In the spinal cord the only lesions which are usually observable occupy 
the anterior cornua. They consist mainly in pigmental degeneration 
and atrophy of the groups of large cells, which tend ultimately to dis- 
appear completely. Herewith, however, is usually associated more or 
less sclerotic change in the tissues in which these cells are imbedded. 
The affection is obviously inflammatory, and although commonly in- 
volving the neuroglia as well as the nerve-cells, is sometimes limited to 
these cells, or to these and to the portions of neuroglia immediately 
surrounding each. Whence Charcot regards the inflammatory process 
as commencing in the nerve-cells, and as implicating the neuroglia 
secondarily only. The morbid process affects the anterior cornua in 
different regions, and by no means necessarily symmetrically ; it may 
involve them in scattered patches, or pretty uniformly, and throughout 
a considerable vertical extent. The diseased cornua ultimately shrink 
in proportion to the degree and duration of the morbid process. 

The motor nerves are involved secondarily to the spinal cord, and 
only at a comparatively late period of the disease. They undergo 
atrophy, the ultimate tubules diminishing in size and tending to lose 
their myeline sheaths. The muscles which are implicated in the dis- 
ease shrink rapidly. In the first instance the only obvious and con- 
stant change is a diminution in their diameter, with some hyperplasia 
of the cells belonging to the sarcolemma, and, according to some ob- 
servers, more or less overgrowth of the intervening connective tissue. 
But even in the early stage a few muscular fibres will often be found 
to have lost their transverse striation and to have become granular. 
At a late period of the disease the atrophy of the fibres has become 
more complete, and they not unfrequently, but by no means necessarily, 
present well-marked fatty degeneratien. At this time, also, there is 
often more or less increase of intervening connective tissue, and some- 
times a large accumulation of fat. The consequences, as regards the 
general form and bulk of the muscles, are very various : in some cases 
they appear simply shrunk to an extreme degree; in other cases they 
are found to retain more or less of their normal size and shape ; and 
occasionally they present a positive increase of bulk, owing to the accu- 
mulation between their fibres of adipose or fibrous tissue. 

Symptoms and Progress. — The onset of infantile paralysis is usually 
sudden, and marked by more or less intense fever, occasionally attended 
with convulsions, coma, or other cerebral symptoms. The duration of 
this febrile attack, which, however, is not always present, varies from 
a few hours to a couple of weeks. The paralytic condition of the mus- 



920 



DISEASES OF THE NERVOUS SYSTEM. 



cles for the most part conies on quickly and unexpectedly. Sometimes 
the child is found paralytic on waking up from sleep ; sometimes on 
the subsidence of coma or convulsions, or on the disappearance of some 
specific fever or of the special fever of the disease, or in the course of 
that fever. The paralysis increases rapidly from the moment of its first 
appearance, so that at the end of a day or two, sometimes, however, 
after a longer interval, it has attained its maximum degree and extent. 
Its extent varies of course in different cases ; sometimes both arms and 
legs are uniformly and completely paralyzed ; sometimes the legs only; 
sometimes the arms only ; sometimes a single extremity ; and some- 
times, and on the whole more commonly, groups of muscles belonging 
to one limb or to several limbs. The paralysis is marked from the 
first by flaccidity of the muscles, and by abolition or impairment of 
reflex excitability. Moreover (and this is a point of capital importance), 
great impairment or absolute abolition of electrical contractility rapidly 
supervenes in the affected muscles, so that at the end of five days, or 
it may be a week, many of the muscles may have entirely ceased to 
contract under the influence of Faradization. Occasionally pain in the 
back and pain on movement of the limbs would appear to attend the 
commencement of the disease, but these phenomena form no essential 
feature of its clinical history, and are certainly in a large number of 
cases wholly wanting. According to Dr. West, more or less cutaneous 
hyperesthesia is present at this time, and may continue for several 
weeks ; but this is far from being a constant phenomenon. Indeed, it 
may be regarded as characteristic of infantile paralysis that absolute 
paralysis of certain muscles, attended with flaccidity and loss of reflex 
and electric contractility, 1 is linked with an almost total absence of 
pain, with retention of cutaneous sensibility, perfect control over the 
rectum and the bladder, and a total absence of all tendency towards 
inflammation of the urinary organs, the formation of bedsores, or the 
appearance of other cutaneous inflammations. The first stage of the 
disease characterized by the phenomena which have been just enume- 
rated lasts from two to six months, sometimes, however, a longer, 
sometimes a shorter time, and is then followed by the second stage, 
which lasts probably for another six months. During this stage more 
or less amendment generally takes place ; certain of the muscles which 
had been paralyzed, and more especially those in which electrical con- 
tractility had not been wholly abolished, slowly regain their normal 
reflex and electrical properties and their power of spontaneous inove- 



1 Note in reference to Faradie and Electric Contractility . — Whilst the section on 
diseases of the nervous system was going through the press, it struck us that the 
terra "electric contractility," which has frequently been employed in it (in accord- 
ance, we believe, with general usage) might with advantage have been replaced by 
the term " Faradie contractility." Such a change, however, made in the course of 
the section, would only have led to confusion, and the expression has therefore been 
retained throughout. We wish it, however, to be clearly understood that wherever 
the term electric contractility is employed without qualification, it means exclusively 
contractility excited by the Faradie current. The distinction is an important one 
in reference to diagnosis, because in those cases in which Faradie contractility is 
speedily lost or abolished, contractility to the continuous current for the most part 
tends to become augmented. 



INFANTILE SPINAL PARALYSIS. 



921 



ruent ; a greater or lesser number, however, of the muscles which had 
lost their electrical contractility probably remain (singly or in groups, 
or occupying the whole of one or more limbs) permanently paralyzed; 
and not only remain paralyzed, but undergo more or less rapid atrophy. 
Any improvement, excepting in those muscles which are already in 
progress of amendment, can scarcely be hoped for after the lapse of 
eiffht or ten months from the commencement of the disease. 

The changes which now slowly ensue are interesting. In the first 
place the permanently paralyzed muscles, which had already perhaps 
given indications of shrinking at the end of a month from the begin- 
ning of the disease, become rapidly atrophied, generally much reduced 
in size, but sometimes retaining more or less of their natural bulk in 
consequence of overgrowth of interstitial connective tissue and fat. 
They continue perfectly limp, and wholly impassive under the influence 
of every kind of stimulus. In the second place, it frequently happens 
that the bones of the affected members become arrested in their de- 
velopment, and are consequently at the time of full growth thinner and 
shorter, sometimes considerably shorter, than they should be. This 
consequence has been observed several times by Volkmann in cases in 
which the primary disease was of short duration, and in which the 
paralysis had wholly disappeared. In the third place, the paralyzed 
limbs show a striking and permanent diminution of temperature, a 
diminution which is more marked than in other forms of paralysis 
affecting the limbs. It appears to be connected with a remarkable 
diminution in the bore of the bloodvessels. In the fourth place, various 
deformities, mainly of the hand and foot, are apt to ensue. These 
generally begin to show T themselves about the end of the first year, and 
depend apparently on the unequal degree in which opposing muscles 
are affected, and on the predominant action therefore of the healthy or 
of the less completely paralyzed muscles. The production of these 
malformations is largely aided by the remarkable laxity of the liga- 
ments, which is also usually present in these cases. The most common 
deformity of the foot is talipes equinus. 

Cases of infantile paralysis occasionally depart from the type which 
has been sketched above. Sometimes the disease lasts for a few days 
or a few weeks only, and complete restoration to health ensues ; some- 
times the paralysis, instead of being developed with sudden intensity, 
creeps on gradually and attains its full development only after some 
length of time ; sometimes, again, the patient suffers from occasional 
exacerbations or relapses. 

Treatment — In the early stage of infantile paralysis, treatment must 
be in the main expectant. Salines, laxatives, and other febrifuge medi- 
cines may be used with some advantage, and in some cases perhaps 
counter-irritation, or the abstraction of blood by leeches or cupping- 
glasses applied in the course of the spine. The patient should, of 
course, be kept absolutely at rest, and careful attention should be be- 
stowed in order to relieve symptoms and obviate the occurrence of 
complications. After, however, all febrile symptoms have passed away, 
and all acute inflammatory mischief has subsided, which will probably 
be at the end of three or four weeks, it will be necessary to adopt meas- 



922 



DISEASES OF THE NERVOUS SYSTEM. 



ures to promote the restoration of those muscles which are capable of 
restoration. The affected muscles may be divided into three categories : 
first, those which, though paralyzed, have their electric contractility but 
slightly affected ; second, those in which the electric contractility is 
much enfeebled; and, third, those which fail to respond to the action 
of any form of electricity. Muscles belonging to the first category 
tend to recover completely, independently of all treatment ; but never- 
theless the periodical application of galvanism to them tends to hasten 
their recovery. Muscles belonging to the second category for the most 
part undergo more or less considerable atrophy, which may continue to 
progress for many months, and may result in their permanent emacia- 
tion and weakness, even though complete restoration of the nerves and 
nerve-centres in relation with them ultimately takes place. In these 
cases the long-continued and systematic use of galvanism, especially if 
it be commenced early, will often serve to arrest the wasting of the 
muscles, and ultimately to bring them back to the condition of health. 
The prospects as regards the muscles in the third class are much more 
gloomy. They invariably waste rapidly, and in a very large propor- 
tion of cases fail absolutely to undergo any kind of improvement. 
Still, even here, the solicitous and long-continued use of galvanism 
sometimes succeeds in effecting a more or less important improvement. 
It need scarcely be said that the longer recourse to the galvanic treat- 
ment is delayed, the less is the chance which it affords of benefit. 
Nevertheless, a case recorded by Duchenne, in which the complete 
restoration of many muscles of the arm (which had been atrophied 
and had lost all electric contractility for a period of four years) was 
effected by means of Faradization applied periodically during the space 
of two years, proves that we need not despair even when circumstances 
seem most adverse. An important result to be derived from electricity, 
even when it fails to cure absolutely, is the prevention of the deformi- 
ties due to the unequal action of antagonistic muscles. Faradization 
of the affected muscles is the mode of treatment specially recommended 
by Duchenne. He objects to the use of the continuous current, at all 
events for young children, on the ground of the pain which it produces 
at the points of application. There is no doubt, however, that the 
continuous current slowly interrupted is yet more potent in this case 
than Faradization. In conjunction with electricity, other measures 
may be used to improve the condition of the muscles ; among which 
may be enumerated exercise, rubbing, shampooing, baths, and me- 
chanical measures to obviate the tendency of certain muscles to con- 
tract and to cause deformity. Iron and other tonics are also, in a 
certain sense, useful. Strychnine has been especially recommended. 

The treatment of the results of infantile paralysis belongs to the 
surgeon. 

Adult Spinal Paralysis. 

Both Duchenne and Charcot have published cases (and, indeed, it 
seems probable that such cases are not uncommon) in which adults 
have been attacked with disease resembling in all essential particulars 
infantile paralysis. The recorded cases show that it comes on in adults, 



GENERAL SPINAL PARALYSIS. 



923 



as in children, with more or less severe febrile symptoms, lasting, it 
may be, for a few days, attended with or followed by motor paralysis 
of a greater or lesser number of the voluntary muscles, but without 
implication of the cutaneous sensibility or loss of control over the rec- 
tum or bladder, or tendency to the formation of bedsores ; that the 
muscles are flaccid, incapable of excito-motor action, and tend rapidly 
to lose their electro-contractility, and to waste; and that, after the 
paralysis has reached its highest degree, more or less amendment takes 
place in some of the muscles. It not uncommonly happens in the 
case of the adult, as probably happens also in the child, that pain in 
the spine, with forward curvature, and some degree of pain in the 
limbs, attend the onset of the disease. The chief point in which the 
history of the disease in the adult differs from that of the disease in 
children is the necessary absence from it of all mention of the various 
deformities resulting from defective development; the bones do not 
become shortened, and deformities connected with the joints are less 
extreme. 

The pathology and treatment of this affection are the same as those 
of the infantile disorder. 

General Spinal Paralysis. 

Definition. — The malady referred to under the above name is in 
the third edition of Duchenne's treatise De I' Electrisation Localisee, 
entitled, " Paralysie g^nerale spinale anterieure subaigue." It is char- 
acterized by a more or less general paralysis, with wasting and flac- 
cidity of the muscles, and marked loss of electrical contractility, unat- 
tended with implication of the rectum or bladder, or with brain symp- 
toms, and tending in many cases to end in recovery. 

Causation. — The causes of this affection are not known. It has 
been referred to exposure to cold and wet. There is no reason to 
regard it as hereditary. It comes on mainly between the ages of thirty- 
five and forty. 

Morbid Anatomy. — The anatomical lesion which underlies the phe- 
nomena by which the presence of general spinal paralysis is revealed 
has not yet been ascertained, but there is reason to believe that the 
disease resembles acute spinal paralysis of children and of the adult, 
in the facts that the parts which are specially implicated are the 
anterior cornua of the gray matter of the cord, and that the lesion is 
inflammatory. 

Symptoms and Progress. — The paralytic phenomena may commence 
in the upper extremities, and thence, travelling downwards, gradually 
become general, or they may take their origin in the legs, and thence 
extend upwards to the rest of the body. The latter course is by far 
the most common. In that case the patient first experiences weakness 
in one or both of his lower extremities ; if in both, with predominance 
in one of them. If a careful examination be made at this time, it will 
generally be found that the flexors of the foot on the leg suffer first, 
and most severely, then those of the thigh on the trunk, and subse- 
quently the extensors of the leg upon the thigh. The paralysis in- 



924 



DISEASES OF THE NERVOUS SYSTEM. 



creases progressively until the patient can neither stand nor walk, and 
ultimately his limbs become entirely motionless. No trembling, no 
convulsive movements, no incoordination, no rigidity or contraction 
attends the progress of the disorder. The affected muscles are, how- 
ever, flaccid from the beginning, and very rapidly, though somewhat 
irregularly; lose their electrical contractility, until at length, as some- 
times happens, it ceases totally. Very soon, also, the paralyzed mus- 
cles undergo atrophy — the atrophy not affecting single muscles, as in 
progressive muscular atrophy, but involving all the paralyzed muscles, 
coetaneously, so that the limbs shrink in their whole extent, and ac- 
quire a resemblance to those of a mummy. The surface at the same 
time is apt to become cold and livid. The paralysis remains limited, 
for a longer or shorter time, to the lower extremities. In some cases 
the hands begin to lose power ere the affection of the lower limbs is 
five or six weeks old. In other cases the upper extremities are not 
involved until after the lapse of several months or years. But when 
once the paralysis has reached them, it pervades them progressively 
and rapidly, first attacking the extensors of the fingers, and then 
taking much the same course as it previously took in the lower ex- 
tremities. Subsequently the muscles of the trunk and those of the 
head and neck become implicated. Generally the paralysis is more 
marked on one side of the body than the other. If the paralysis be 
not arrested in its course, or do not undergo amendment, it extends at 
length to the muscles supplied by the nerves of the medulla oblongata, 
whence result difficulty of articulation, difficulty of deglutition, and 
respiratory trouble. 

The progress of the disease may be uniform and continuous, or it 
may be interrupted from time to time by long intervals, during which 
the symptoms remain in abeyance or undergo more or less obvious 
amendment. Sometimes the patient recovers completely, only to have 
a relapse at some subsequent period. Not unfrequently patients suc- 
cumb, especially under the effects of implication of the medulla ob- 
longata, or from syncope. On the other hand, many persons recover 
absolutely, even after they have suffered from the disease for some 
months or years, and even after the wasting of the limbs and the loss 
of electrical contractility have persisted for a considerable period. 
The duration of the disease varies between a few months and many 
years. 

Among the more striking characteristics of general spinal paralysis 
are : its insidious origin, unattended with febrile or other symptoms ; 
its progressive invasion of all the voluntary muscles, and the rapid 
loss by these of electric contractility and bulk ; the wasting of the 
limbs in mass, and not muscle by muscle ; the absence of all paralytic 
tremblings and all convulsive movements ; the retention of cutaneous 
sensibility, of control over the emunctories, and of the mental faculties; 
and the tendency which is manifested towards ultimate recovery. 

Treatment. — In treating cases of general spinal paralysis, it must 
always be remembered that many cases ultimately do well quite irre- 
spective of medical treatment. There is, indeed, but little to be done 
medicinally. The usual round of drugs which are employed in nervous 




PROGRESSIVE MUSCULAR ATROPHY. 



925 



disorders may be tried. With more hope of benefit galvanism, periodi- 
cally and persistently administered, may be had recourse to in the 
treatment of the paralyzed muscles. 



commencing in certain muscles, usually those of one hand, next in- 
volving, as a rule, corresponding muscles on the opposite side of the 
body, and gradually spreading to other muscles of the limbs and 
trunk. 

Causation. — Progressive muscular atrophy occurs both in children 
and adults, and principally in males. Its causes are obscure. It has 
been traced apparently to exposure, to excessive bodily or mental ex- 
ertion, and to violent emotions ; but mainly it appears to be an heredi- 
tary affection. In almost all cases of its occurrence in children which 
have come under Duchenne's observation, the disease appears to have 
been hereditary. 

Morbid Anatomy. — The pathology of this affection differs little from 
that of the spinal paralysis of children and of adults. The parts which 
have been found post mortem to be affected are in this case, as in those, 
the anterior cornua of the gray matter of the cord, the motor nerves 
which emerge therefrom, and the muscles which these nerves supply. 
The affection of the cord is in many cases limited to certain of the groups 
of large cells ; the cells undergoing the various forms of degeneration 
which have been already described, and finally, it may be, disappear- 
ing altogether; or it may include with these changes a greater or less 
amount of sclerosis of the contiguous portions of the anterior cornua, 
with corresponding atrophy of the nerve-tubules. In the early stage 
the bloodvessels of the affected parts are enlarged and their walls thick- 
ened. The anterior nerve-roots, which are connected on the one hand 
wit h the diseased portions of cord, on the other with the affected muscles, 
undergo similar changes to those which have been described in connec- 
tion with infantile paralysis ; but the degeneration is never so extreme 
or general, nor does it distinctly manifest its presence until the muscular 
atrophy has made considerable progress. The muscular change essen- 
tially consists in a mere attenuation of the muscular fibres, with more 
or less proliferation, of an abortive character, of the cells of the sarco- 
lemma. Granular and fatty degeneration, with disappearance of the 
transverse striae, may supervene at a late period of the disease ; but it 
is merely a secondary phenomenon, and one which seems to have no 
special significance.. Hypertrophy of the connective tissue investing 
the muscular fibres, and accumulation of fatty matter in the same situa- 
tion, are not uncommon. The affection of the nerve-centres is dis- 
tinctly inflammatory, and precedes and causes the lesions of the motor 
nerves and muscles. 

Symptoms and Progress. — Progressive muscular atrophy, unlike acute 
spinal paralysis, comes on insidiously. Its advent is unattended with 
fever or other obvious constitutional disturbance. Indeed, the first 
indication of its presence is, almost without exception, the wasting and 




926 



DISEASES OF THE NERVOUS SYSTEM. 



loss of power of some muscle or group of muscles. The muscular 
atrophy may commence at any part, but most commonly commences in 
the hand and more especially in the right hand, whence it spreads first 
to the corresponding muscles of the opposite side of the body, then to 
those of both forearms, and presently becomes distributed with more 
or less irregularity, but symmetrically, throughout the trunk and lower 
extremities. 

When it takes the orthodox course, it is the muscles of the ball of 
the right thumb which are usually first affected. Then the muscles of 
the hypothenar eminence and the interossei suffer; and the hand 
acquires an almost pathognomonic claw-like form. Next the muscles 
of the forearm waste, w T ith some irregularity as to the order of their \ 
wasting. Subsequently the muscles of the upper arm and shoulder 
suffer, the triceps for the most part retaining its normal condition longer 
than the others. The muscles of the trunk usually suffer coetaneously 
with those of the upper arm, but are involved irregularly. The usual 
order, however, of their involvement is, according to Duchenne : first, 
the trapezius (of which the lower portion suffers earliest), then succes- 
sively the pectorals, the latissimus dorsi, the rhomboidei, the levator 
anguli scapulse, the extensors and flexors of the head, the sacro-lum- 
balis, and the abdominal muscles. When the atrophy has extended 
thus far, the muscles of respiration and deglutition usually become 
affected. The clavicular portion of the trapezius is the last of the 
muscles of the trunk to succumb. The lower extremities are involved 
subsequently to the arms and trunk, but their muscles are apt to suffer 
equally in degree with those of other parts. The muscles which are 
earliest affected are the flexors of the foot on the leg, and those of the 
thigh upon the pelvis. 

Not unfrequently progressive muscular atrophy first shows itself 
among the muscles of the trunk, attacking sometimes the pectorals, 
sometimes the serratus magnus, sometimes the spinal muscles, some- 
times those of the abdomen, and thence extending to the other trunk- 
muscles and to those of the extremities. Its commencement in the 
lower extremities is exceedingly rare. 

A curious circumstance is pointed out by Duchenne, namely, that 
when progressive muscular atrophy attacks young children, its invasion 
is marked by the effacement of some of the muscles of the face ; that 
their expression consequently becomes more or less idiotic, that their 
cheeks become flaccid and their lips large and pendulous ; and that it 
is only subsequently, and it may be after the lapse of years, that the 
muscles of the trunk and those of the limbs partake in the atrophic 
change. 

In addition to the fact that progressive muscular atrophy is a disease 
of an essentially chronic character, and tends from insignificant begin- 
nings slowly to involve a large number of the voluntary muscles of the 
limbs and trunk, it presents several other remarkable features which 
help to distinguish it from acute spinal paralysis and from other spinal 
disorders to which in other respects it has a more or less close resem- 
blance. First, the enfeeblement of the affected muscles does not precede 
the atrophy; it follows upon the atrophy, is due to it, and is propor- 



PROGRESSIVE MUSCULAR ATROPHY. 



927 



tional to it ; and indeed the motor power is not wholly lost until a very 
late stage of the disease, or until the muscles have undergone complete 
atrophy. Second, the electro-contractility of the affected muscles re- 
mains unimpaired, or rather diminishes only in proportion to the ef- 
facement of the constituent muscular fibres, and never absolutely dis- 
appears until voluntary power is wholly lost, namely, when atrophy 
has reached its extreme degree. Third, a very common feature of the 
malady is the presence in the affected muscles of irregular vibratile 
movements of the individual fibres, which may be both seen and felt, 
and which to the eye give, when superficial muscles are under observa- 
tion, an appearance as though innumerable parallel threads were vibra- 
ting more or less rapidly and independently the one of the other. 
These fibrillar oscillations are occasionally so violent as to cause move- 
ments of flexion and extension in the fingers or other parts. They are 
not constant, and are usually evoked either by the patient's effort to 
bring the muscles into action, or by tapping, pinching, or otherwise 
exciting them. They are not peculiar to progressive atrophy, although 
they commonly attend it. Other characters which are common to this 
affection and to the consequences of acute spinal paralysis are a lower- 
ing of the temperature of the affected limbs, absence of spinal or neu- 
ralgic pain, absence of tendency to the formation of bedsores or to the 
appearance of cutaneous eruptions, and the retention of control over 
the emunctories. Cutaneous sensibility is generally retained. It is 
well to bear in mind that the wasting of the muscles is often concealed 
by the presence of an excess of subcutaneous fat, and that hence the 
true condition of things can often only be determined by careful investi- 
gation, and especially by the use of galvanism. 

The course of progressive muscular atrophy is always slow and ir- 
regular. It may appear in some of the muscles of the face or hand, 
and years may elapse before it extends thence either to neighboring 
muscles or to the corresponding muscles of the opposite side of the 
body. Or it may invade the muscles of the arms or legs with com- 
paratively great rapidity, and then a long interval of quiescence may 
ensue. It may even become arrested in its onward progress never to 
be reawakened. Most commonly, however, it advances either uni- 
formly or by fits and starts, until the patient becomes utterly helpless. 
The duration of the affection is very various. In many cases the pa- 
tient survives for eight or ten years, or even for twice that period ; and, 
indeed, there is nothing to interfere with the duration of life unless the 
muscles of respiration or those of deglutition become involved. If this 
happen, the patient is liable to be cut off either by inability to swallow, 
by choking, or by difficulty of breathing, and the pulmonary compli- 
cations which are then so apt to ensue. If these important parts are 
early implicated, the patient may succumb within two or three years 
from the commencement of his malady. 

Treatment. — The treatment of progressive muscular atrophy calls for 
no special observation. It may be the same as has been recommended 
for the chronic stages of acute spinal paralysis, and especially the sys- 
tematic use of electricity to the affected muscles. M. Duchenne, who 
strongly urges the beneficial influence of this treatment, says that the 



928 



DISEASES OF THE NERVOUS SYSTEM. 



progress of the disorder may be sometimes arrested by it, and that mus- 
cles not too far advanced in atrophy may occasionally be restored by 
it. He prefers Faradization applied in turn to each affected muscle, 
but recommends also the concurrent use of the direct current, constant 
or interrupted. He specially advocates the solicitous treatment of those 
muscles which are the most important either for the maintenance of 
life or the movement of the limbs. The following are some of the rules 
which he lays down. The more a muscle is atrophied, its contractility 
diminished, and its sensibility benumbed, the longer it should be sub- 
jected to the stimulation, the more intense should be the current, and 
the more rapid its intermissions. But when the sensibility returns, it 
is prudent to diminish the intermissions, and abate the intensity of the 
current, and even to abridge the number of sittings, lest unmanageable 
neuralgia be provoked. No sitting should be prolonged beyond ten or 
fifteen minutes, and rarely more than one minute should be given to 
each muscle. 

Lateral Sclerosis. 

Definition. — The affections which it is intended to comprise under 
the above designation are those to which M. Charcot applies the names 
of " Amyotrophies spinales deuteropathiques," and " Sclerose laterale 
amyotrophique." They are essentially characterized, first, as regards 
their morbid anatomy, by a sclerotic change affecting the lateral white 
columns of the cord symmetrically and in their whole length, and in 
the majority of cases extending thence so as to involve more or less of 
the anterior cornua, and occasionally of the sensory elements ; second, 
as regards their clinical phenomena, by paralysis of the limbs with 
rigidity and tendency to contract, associated with more or less wasting 
of the muscles and sometimes with neuralgic pains. 

Causation. — The causes of the inflammatory process which induces 
sclerosis in the lateral columns are various. This lesion is a common 
consequence of the effusion of blood into the substance of the cerebrum, 
or of the presence of a patch of softening, and equally follows the pres- 
ence of any destructive lesion in the crura, pons, medulla oblongata, or 
spinal cord. It is occasionally of idiopathic origin, under which cir- 
cumstances, according to Charcot, it does not appear to be hereditary, 
seems to occur more frequently in women than men, and mainly be- 
tween the ages of twenty-six and fifty. Some patients refer the disease 
to the influence of cold and wet, and some to injury. 

Morbid Anatomy . — The simplest form of lateral sclerosis, both patho- 
logically and clinically, is that which occurs secondarily below the 
situation of some cerebral or other lesion. We have already drawn 
attention to the fact of its occurrence under the conditions here speci- 
fied. In old cases of cerebral haemorrhage or softening, a tract of 
sclerosis, the upward limit of which has not yet been determined, may 
often be traced along the crusta of the corresponding crura cerebri, 
through the pons, into the anterior pyramid, w T hich may be involved 
in pretty nearly its whole horizontal and vertical extent, and along the 
decussation to the opposite side of the cord, in which it occupies almost 
exclusively the lateral white column, being separated however from the 



LATERAL SCLEROSIS. 



929 



surface by a persistent lamina of still healthy white matter. In the 
neck the sclerotic change may extend from the outer angle of the an- 
terior cornu in front to the posterior nerve-root behind ; but in its 
passage down the cord it occupies a smaller and smaller space, both 
relatively and actually, and at the same time limits itself more and 
more to the neighborhood of the posterior cornu and the nerve-fibres 
springing from it. Thus in the middle of the dorsal region its anterior 
limit corresponds to a transverse line drawn through the commissure, 
while in the lumbar enlargement it occupies only the posterior fourth 
of the lateral column. Occasionally the fasciculi of Turck (narrow 
tracts of white matter situated on either side of the anterior median 
fissure, and belonging apparently to the same system as the lateral 
columns) share in the morbid change. It is very rare, however, for 
any other part to be implicated. 

Lateral sclerosis of idiopathic origin affects identically the same 
tracts, but in this case both sides of the cord are as a rule simultane- 
ously implicated, and the morbid process consequently presents a sym- 
metrical character. Another important distinction between the second- 
ary and idiopathic forms of the lesion is afforded by the fact that in 
the former the morbid process rarely extends horizontally beyond the 
lateral white columns, while in the latter such extension constitutes the 
rule. When lateral extension takes place, it is seldom if ever general ; 
comparatively rarely it involves the sensory tracts of the gray matter 
of the cord, the posterior columns, or the posterior roots ; but almost 
always it is the anterior cornua with their group of large cells which 
thus suffer. The anatomical lesion, in fact, which constitutes the basis 
of the group of affections last considered, becomes superadded to the 
primary lesion of the lateral columns. This lateral extension, however, 
does not occur in all situations equally, nor does it take place here and 
there indifferently. It is almost invariably furthest advanced in the 
cervical portion of the cord, and diminishes gradually thence down- 
wards. It occurs, also, though at a comparatively late period of the 
disease, in the medulla oblongata, leading then to special implication 
of the nuclei of the spinal accessory, hypoglossal, vagus, and facial 
nerves. Both the naked-eye and microscopic characters of sclerosis 
have been already sufficiently considered. It needs only to be stated 
here that the sclerotic process in the anterior cornua, which is asso- 
ciated with lateral sclerosis, is undistinguishable from that which occurs 
primarily in them ; and that it is followed sooner or later by the same 
secondary changes in the motor nerves and the voluntary muscles which 
have been already described in connection with infantile paralysis. 

Symptoms and Progress. — The symptoms specially referable to dis- 
ease of the lateral columns are gradually developing paralysis of the 
muscles with which the affected tracts are in relation, attended with 
more or less violent tremors during the attempt to perform voluntary 
movements, and with gradually increasing rigidity, often coming on in 
paroxysms, and easily induced by any kind of irritation. The rigidity 
is at first general, and induces extension of the limbs ; but subsequently 
the flexors tend to overpower the extensors, and the limbs become more 
or less strongly flexed. Besides the sudden spasmodic contractions just 

59 



930 



DISEASES OF THE NERVOUS SYSTEM. 



referred to, the paralyzed muscles are liable to more or less prolonged 
paroxysms of convulsive trembling. The affected muscles do not waste, 
and they retain their electrical contractility and reflex excitability un- 
impaired. Nor is there any loss of sensation or any pain. 

These phenomena are often observed in the lower extremities of per- 
sons who are paraplegic from pressure, or disease, involving a limited 
portion of the length of the cord, and are then referable to the descend- 
ing lesion of the lateral columns which is so apt to ensue in these cases. 
Rigidity and contraction, due to the same cause, are also of common 
occurrence in the paralyzed limbs in cases of old cerebral mischief. In 
idiopathic disease, however, of the lateral columns, the extension of 
disease horizontally into other regions of the cord necessitates the super- 
addition of other symptoms to those which have just been enumerated; 
these are occasionally more or less pain, numbness or tingling from 
implication of the posterior roots or posterior horns, but especially 
more or less rapid wasting of some of the paralyzed muscles from in- 
volvement of the anterior cornua. It must be added that the phenom- 
ena of the idiopathic affection are largely dependent, as regards their 
gravity and distribution, on the longitudinal extent in which the lateral 
columns are implicated, and on the destination of the motor nerves 
whose nuclei suffer from its horizontal extension. 

In the great majority of cases the idiopathic disease comes on insidi- 
ously, without fever or premonitory symptoms other than perhaps some 
numbness or tingling in the limb over which paralysis impends. The 
arms are usually first implicated, first one, probably, and the other 
after a short interval. They become enfeebled and more or less 
emaciated; the enfeeblement, however, precedes the emaciation, or 
goes along with it, and does not, as in wasting palsy, follow it. More- 
over, in the affection now under consideration, the paralysis and wast- 
ing affect all the muscles of the limbs simultaneously instead of, as in 
the other case, creeping from muscle to muscle. Further, the wasting 
muscles are liable, as are those of wasting palsy, to fibrillar vibrations, 
and they retain like them their electric contractility; and, moreover, 
so long as any voluntary power of movement remains in them, such 
movements are generally attended with more or less violent trembling. 
But, in addition to all the phenomena above enumerated, the emaciated 
and paralyzed limbs soon become rigid and contracted, and, as a con- 
sequence of this contraction, deformed. Each arm is kept closely ap- 
plied along the side of the body, and the shoulder resists when we 
attempt to abduct the arm ; the forearm is semiflexed and pronated, 
and cannot be extended or supinated without the use of considerable 
force, and exciting some pain ; the fist is flexed on the forearm, and 
the fingers also are flexed. In the further progress of the case the 
emaciation may become extreme ; and then with the atrophy of the 
muscles their capability of contracting under the stimulus of electricity 
may fail, and their rigidity and consequent contraction may to some 
extent disappear. In some cases the muscles of the neck become rigid, 
like those of the arms, and the patient has pain and difficulty in mov- 
ing his head. 

The atrophy of the arms is in this affection far more rapid than in 



LATERAL SCLEROSIS. 



931 



progressive muscular atrophy, mainly, no doubt, because all the mus- 
cles are involved at one and the same time ; and at the end of four, 
five, or six months, or at the outside a year, the emaciation is as ex- 
treme as we observe it to be in cases of progressive muscular atrophy 
which have been in progress for two or three years. From six months 
to a year or more after the commencement of the disease, the lower ex- 
tremities generally first give signs of involvement. The patient com- 
plains of numbness, tingling, and loss of power in them; but in their 
case there is very rarely any atrophy, owing evidently to the fact that 
the motor nuclei of the dorsal and lumbar regions are scarcely ever in- 
volved. The paralysis of the legs, however, makes rapid progress; the 
patient soon cannot walk without being supported on both sides ; and 
before long all voluntary movement ceases in them. Long ere the 
paralysis is complete the legs are liable to spasmodic contractions, 
which come on without obvious cause, and are readily excited by any 
form of stimulus; the limbs become suddenly rigid, sometimes flexed, 
sometimes extended, and are apt to remain for some time in that con- 
dition. These spasms are especially liable to come on when he at- 
tempts to walk, and then especially cause powerful adduction of the 
thighs, with more or less marked extension at the different joints. 
The extension at the ankle-joints imparts to the feet the attitude of 
talipes equino-varus. Associated with these spasms are more or less 
violent tremblings, which add to the patient's difficulty of walking. 
When the paralysis is complete, the rigidity becomes permanent, the 
legs being in some cases extended, in some flexed, and exceedingly dif- 
ficult to bend or straighten. At this time prolonged paroxysms of 
spasmodic trembling can often be readily induced. After awhile, but 
this is a remote and comparately rare event, the muscles of the legs 
may undergo atrophy like those of the arms ; and with the advance of 
this atrophy the rigidity gradually relaxes. There is no paralysis of 
bladder or rectum, or tendency to the formation of bedsores. 

While the legs are becoming paralytic, or it may be after arms and 
legs have lost all power of voluntary movement, another series of phe- 
nomena gradually supervenes, referable to implication of the motor 
nuclei of the medulla oblongata. These are : paralysis of the lips and 
face, of the tongue, of the soft palate, and of the parts to which the 
vagus is distributed — a group of phenomena which will hereafter be 
considered as a distinct affection, under the name of " glosso-labio- 
laryngeal palsy." 

The progress of idiopathic lateral sclerosis is not always in accord- 
ance with the above sketch. Sometimes it commences in the lower ex- 
tremities, sometimes it is limited to one arm or leg, or assumes a hemi- 
plegic form, and rarely it first reveals itself by implication of the nerves 
of the medulla oblongata. 

The prognosis of the disease, at all events when it presents distinc- 
tive characters, is exceedingly gloomy. Its various stages follow one 
another surely and rapidly, and death usually takes place within one, 
two, or three years from the commencement of paralytic symptoms. 
The contrast in this respect between lateral sclerosis and wasting palsy 



932 



DISEASES OF THE NERVOUS SYSTEM. 



is very striking. Death is generally due to accidents connected with 
the involvement of the nerves of the medulla oblongata. 

Treatment. — It is needless to endeavor to lay down rules for the 
treatment of this disease. All that can be done is to attend to the 
general health, to resort to galvanism, friction, and such-like measures, 
and to obviate as far as possible the various discomforts and dangers 
to which the patient is exposed. 

Tabes Dor salts. (Locomotor Ataxy.) 

Definition. — By the above terms is understood a peculiar affection 
characterized anatomically by sclerosis of the posterior columns of the 
cord, clinically by loss of co-ordinating power in the lower extremi- 
ties, gradually increasing in degree and extent, and generally sooner or 
later involving the upper extremities and other parts. Various ner- 
vous lesions, which need not now be specified, are frequently associated 
with the muscular incoordination. 

Causation. — The causes of locomotor ataxy, like those of most other 
affections of which a sclerotic condition of the nervous centres forms 
the anatomical basis, are exceedingly obscure. The disease has been 
referred by some to sexual excesses, by some to exposure to cold and 
wet, by some to over-exertion or to injury or shock. But little more 
can be said positively than that in many cases some one of these various 
conditions has preceded the occurrence of the nervous phenomena. In 
the greater number of cases, however, no cause whatever can be assigned. 
The disease is occasionally hereditary, or runs in families, and, further, 
seems not unfrequently to be associated in families with insanity, epi- 
lepsy, and other affections of the nervous system. It rarely occurs in 
women ; and in those persons whom it attacks generally first makes its 
appearance between the ages of twenty and forty-five. It sometimes, 
however, comes on at an advanced period of life, and sometimes about 
the age of puberty. 

Morbid Anatomy. —The specific lesion of locomotor ataxy consists 
in sclerosis of the posterior columns of the cord: both columns being, 
as a rule, equally affected,, and the morbid change being most advanced 
in the lower part and diminishing from below upwards. In many cases 
of locomotor ataxy the posterior columns are involved in their whole 
horizontal extent. But it is shown by Charcot that such an amount of 
disorganization is unnecessary for the production of the characteristic 
symptoms of the disease; that in some cases the posterior pyramids 
remain perfectly healthy; and that, in fact, the tracts whose lesions 
induce ataxic symptoms are two narrow bands of white matter lying, 
one on each side, between the inner and posterior aspect of the posterior 
cornu and nerve-roots on the one hand, and the posterior pyramid on 
the other. The sclerotic change occurring in these parts calls for no 
specific naked-eye or microscopic description; the affected columns be- 
come indurated, gray, and translucent: in the early stage of disease a 
little swollen, but at a later period notably diminished in bulk. The 
disease, however, rarely remains strictly limited to the tracts which 
are its primary seat ; in a large number of cases (as has been already 



TABES DORSALIS. 



933 



indicated) the posterior pyramids become involved; and generally the 
internal radicular fibres of the posterior roots of the nerves, and more 
or less of the adjoining parts of the posterior cornua, become implicated 
to some extent. Occasionally, also, the disease invades the lateral 
columns, and occasionally even reaches to the anterior cornua : not, 
however, Charcot thinks, by gradual involvement of all the interme- 
diate tissue, but by extension along the internal radicular fasciculi. 

Symptoms and Progress. — The invasion of locomotor ataxy is some- 
times quite sudden ; in other words, impairment of co-ordinating power 
is the first symptom to declare itself. In the great majority of cases, 
however, the specific characters of the disease are only revealed after 
the patient has suffered for weeks, or months, or years, sometimes many 
years, from premonitory symptoms. These are very various, but many 
of them are full of significance, and most belong equally to the fully 
declared disease. The more important of them are as follows : First, 
Pains. These are of various kinds and are referable to various parts. 
The most common are momentary sharp shooting pains, following the 
course of certain nerves, for the most part connected with the trunk or 
lower extremities. An erythematous or vesicular eruption sometimes 
appears in the area? of distribution of the affected nerves. Another 
variety of pain is of a boring or stabbing character, and is generally 
limited to certain definite regions in the neighborhood of the joints or 
along the back, and its occurrence is usually associated with hyperes- 
thesia of the same parts. A third variety is of a constrictive character; 
it mostly aifects the trunk, but may involve the limbs or any part of 
them. These various forms of pain are often associated. The last of 
them is more or less persistent; but the others come on in momentary 
twinges, and their continuance is effected usually by a more or less 
rapid succession of such twinges. They sometimes come on at irregular 
and long intervals, and then not unfrequently continue by successive 
paroxysms for several hours or several days; sometimes they recur 
several times daily; sometimes they are constant, and entirely deprive 
the patient of rest. They are generally worse at night-time. Pains 
referable to the viscera are also not unfrequent. Among them may be 
included pain in the bladder attended with frequent desire to micturate, 
pain in the urethra excited by the act of micturition, and pain in the 
rectum as if the bowel were being distended, associated with violent 
tenesmus. The most important and characteristic of them, however, 
are attacks of gastralgia of extreme intensity, attended with vomiting, 
faintness, deranged action of the heart, and an extreme sense of illness. 
The pains in the stomach shoot thence to the back, around the abdo- 
men, and in various other directions. Second, Paralysis of motor or 
sensory nerves. These are sometimes temporary, and then perhaps recur 
at intervals; sometimes they become permanent. Among the least 
common of them are hemiplegia, and anaesthesia in the area of distribu- 
tion of the fifth pair; among the most common, paralysis of the external 
or of the internal rectus of the eye or of other muscles supplied by the 
third pair. Third, Affections of the eye and ear. We have already 
referred to the fact that the patient may have an internal or external 
squint, or ptosis. It may be added that extreme contraction of the 



934 



DISEASES OF THE NERVOUS SYSTEM. 



pupil is a marked feature of the disease; that the pupils are sometimes 
unequal, and that the contracted pupil is apt to dilate under the influ- 
ence of the attacks of pain to which the patient is subject. Bat besides 
these conditions, which are obvious to casual observers, there are others 
of yet greater significance and importance. The patient's eyesight in 
many cases gets defective ; he sees double, or his vision becomes dim 
or indistinct; he cannot distinguish small objects or the contours of 
objects so clearly as he formerly did ; or his field of vision becomes 
contracted, limited perhaps to one side; or there is some failure in 
power of distinguishing colors — he recognizes yellow and blue, but fails 
to distinguish red and green, and the various secondary tints in the 
production of which these colors are concerned ; or these various con- 
ditions are associated in a greater or less degree. These affections of the 
eyesight tend slowly to increase, and at length culminate in absolute 
blindness. They are due to progressive gray atrophy of the optic disk, 
revealed ophthalmoscopically by chalkiness and opacity, with absence of 
the marginal rosiness of tint, and inability to trace the trunk-vessels of 
the retina as they sink into the substance of the optic nerve : they seem 
to terminate abruptly. The atrophy, according to Charcot, is due to a 
change occurring in the optic disk (identical with that which goes on in 
the posterior columns of the cord) and extending thence gradually 
backwards along the optic tract as far at least as the corpora geniculata. 
Headache, referred to the back of the head and forehead, and neuralgic 
pains in the course of the branches of the fifth pair, and in the eyeball, 
frequently attend the above visual lesions. Deafness in one or both 
ears is not uncommon. Fourth, Affections of the joints. These are of 
occasional occurrence; they are observed mainly in the knees and hips, 
sometimes in the shoulders. They consist in rapid effusion into the 
joints and into the tissues which surround them, taking place with little 
or no pain and no fever, and followed at the end of some weeks or 
months by restoration to health. Occasionally they end in erosion of 
the ends of the bones, or disorganization of the joint, followed after a time 
by dislocation. Lastly, among other occasional precursory symptoms 
may be enumerated nocturnal incontinence of urine; spermatorrhoea, 
sometimes attended with erection and voluptuous sensations, sometimes 
occurring independently of erection or of orgasm ; a peculiar aptitude 
for repeating the sexual act many times within a short period; and, 
lastly, a permanent acceleration of pulse, attended, according to M. 
Eulenburg, with habitual dicrotism. 

The explanation of the phenomena which have just been enumerated 
is for the most part obvious. They are dependent on the progress and 
distribution of the morbid process which is going on in the nervous 
centres, but which has not yet destroyed, sufficiently to cause obvious 
incoordination, those portions of the cord which minister to the co- 
ordinate actions of the lower extremities. Thus the various forms of 
neuralgic pain and of cutaneous eruption are due to the implication of 
the intrarhachidian portions of the sensory nerve-roots ; the affections 
of the eyes are referable to involvement of the ophthalmic and auditory 
nerves, or their nuclei ; there are good grounds for believing that the 
affections of the joints are the consequence of implication of the ante- 



TABES DORSALIS. 



935 



rior cornua, and that various phenomena, such as those presented by 
the pupils and those connected with the action of the heart and char- 
acter of the pulse, are of sympathetic origin. 

The so-called " premonitory " symptoms are in truth an integral 
part of the disease, and if recognized, may be taken as sure evidence 
of the insidious progress of those central organic lesions which ulti- 
mately induce the proper ataxic phenomena. Some one or more of 
these premonitory symptoms may continue for years before the occur- 
rence of obvious ataxia, the disease may even stop short with them, 
but in many cases those which first made their appearance undergo 
gradual aggravation, others become superadded to them, and presently 
the ataxic phenomena supervene and become mingled, as it were, with 
them. In other cases again, want of co-ordination in the movements 
of the lower extremities is the very first indication of nervous disease, 
and various of the phenomena hitherto spoken of as prodromal appear 
as complications only during its later progress. 

The earliest of the special phenomena of locomotor ataxy is the 
gradual supervention of a certain difficulty in walking, frequently 
associated with more or less numbness and tingling of the toes and 
feet. The difficulty is peculiar in its character ; it does not consist in 
any loss of muscular power or any inability to take long walks with- 
out discomfort or fatigue, but in a certain clumsiness or uncertainty 
which manifests itself, epecially when the patient first rises from his 
seat, or when he is endeavoring to avoid obstacles, or when he attempts 
to turn suddenly on his heels, or to go upstairs. It becomes especially 
obvious in the dusk — and, indeed, the very first indication of disease is 
sometimes the difficulty which the patient experiences in walking in 
the dark. Under all these circumstances his movements become more 
or less tumultuous, and there is an obvious difficulty in the mainte- 
nance of his equilibrium. This difficulty becomes evident in the most 
marked manner, even in the very earliest stage of the disease, when 
the patient is made to stand blindfold with his feet together. At once 
he begins to totter and to sway, and unless he opens his eyes or is sup- 
ported by others, soon falls to the ground. With the progress of the 
disease the movements all become more tumultuous, and the difficulty 
of progression proportionately increased ; the patient now perhaps 
experiences considerable difficulty in assuming the erect posture ; in 
endeavoring to attain it his legs jerk here and there, apparently urged 
by an uncontrollable impulse, and he has to resort to a stick or the 
arm of his chair, or to a friendly hand to aid him in his efforts. When 
once he is on his legs, he pauses for awhile to balance himself, and then 
starts off with his body bent forwards and his legs apart. Every move- 
ment of his legs is now tumultuous; the leg with which he steps out 
is lifted from the ground and thrown forwards and upwards with need- 
less violence, and is then brought to the ground with equally unneces- 
sary force, and even when on the ground still presents a tendency to 
jerk, which may be continued even while the other leg is in its turn 
executing its series of awkward progressional movements. Thus the 
patient continues to walk either without assistance or with the aid of 
a stick or chair, or between a couple of friends, according to the stage 



936 



DISEASES OF THE NERVOUS SYSTEM. 



which his loss of co-ordinating power has reached. But even now (if 
he be able to walk alone or with a stick) his movements become a little 
less wild after he has taken a few steps, and he may continue to walk 
with excessive violence of movement, no doubt, and with short hurried 
steps and with the body thrown forwards, but nevertheless with con- 
siderable power and efficiency. Patients in this state will sometimes 
walk ten, a dozen, or twenty miles at a stretch, with comparatively 
little fatigue, but in some cases the mere violence of his muscular 
movements involves such rapid exhaustion of power that the sufferer 
can scarcely do more than walk across the room. A time, however, 
comes sooner or later in which his want of control over the movements 
of his lower extremities becomes so extreme that it is absolutely im- 
possible for him to make a step or two consecutively, or even to stand. 
His legs, when he attempts to use them, move, as Trousseau observes, 
like those of a puppet or a marionette. Thenceforward he is confined 
to his chair or to his bed. It is a remarkable fact, for the due appre- 
ciation of which we are indebted to Duchenne, that the muscles of the 
affected limbs retain, as a rule, their bulk, their tonicity, their elec- 
trical contractility, and their strength little, if at all, impaired, not 
only so long as the patient can walk or stand, but long after his limbs 
have become absolutely helpless. And often, at a time when the pa- 
tient cannot rise from his chair or stand, he can freely execute move- 
ments of extension and flexion as he sits or lies, and successfully resist 
all manual efforts on the part of his physician to extend or flex his 
legs. The numbness and tingling, to which reference has already been 
made, generally persist, and for the most part increase in degree and 
in extent, and always from below upwards. There is sometimes total 
abolition of cutaneous sensibility in the feet, and there may be some 
impairment of it, extending even to the abdomen. Occasionally it is 
absent. This impairment of sensibility gives to the patient the impres- 
sion that his feet are swollen and soft, or that they are enveloped in 
some thick soft covering, and when he stands or walks that he treads 
on sponge or wool, or some other yielding and elastic material, or even 
that he treads on air. However great the loss of tactile sensibility, 
that which takes cognizance of differences of temperature usually sur- 
vives to the last. 

The symptoms of ataxy do not generally remain limited to the lower 
extremities. In most cases, sooner or later, numbness, at first perhaps 
occasional, but after awhile permanent, is complained of in the tips of 
one or two of the fingers, generally the little and ring fingers; and the 
numbness may remain thus limited, or gradually involve more and 
more of the hand and arm, always, however, continuing most highly 
developed in the parts which were first attacked. In association with 
this numbness, more or less clumsiness in the movements of the fingers, 
and probably of the hands and arms, may be observed. The patient 
experiences considerable difficulty in performing all delicate manipula- 
tions ; he cannot pick up a pin lying upon a hard smooth surface, he 
cannot button or unbutton his clothes or tie a bow, especially if he be 
unable to direct the operation with his eyes ; in grasping a pen or any 
other similar object which is handed to him he first opens his hand 



TABES DORSALIS. 



937 



wide and then closes it with more or less violence upon it, entirely fail- 
ing to execute those delicate combined movements which are necessary 
j to the precision of his performance, and which impart such grace to the 
natural movements of the hand. The same clumsiness is observable 
in his efforts to transfer the object from one hand to the other, and if 
it be a pen, in acquiring that hold of it which is proper for writing. 
Further (and this is a defect belonging equally to the lower extremi- 
ties, but less readily recognized in their case), the patient is unable with- 
out the assistance of his eyes to judge of the position of his hands, or so 
to adjust the action of his muscles as to determine accurately the direc- 
tion or extent of the movements of his arm. Hence, if his eyes be 
closed, he cannot if he wishes to clasp his hands, bring them together 
with any certainty ; they are brought towards one another at different 
elevations, or one in front of the other, and it is only after several fail- 
ures have been made that they finally meet. Similarly, if he tries to 
touch his nose with his finger, he probably strikes his eye or his fore- 
head or his mouth. The voluntary movements of the arms are often 
effected by a series of jerky movements. But, notwithstanding the 
widespread affection of his voluntary muscles, he retains perhaps dur- 
ing the whole duration of his illness perfect control over the rectum 
and bladder, and has no tendency to bedsores. 

Various other phenomena supervene, or are apt to supervene, in the 
course of the disease. In some cases the muscles of the trunk and of 
the head and neck become implicated in the same way as the muscles 
of the extremities, and the patient's trunk and head and neck then exe- 
cute slight oscillatory movements Avhen he sits up unsupported. In 
some cases difficulty of articulation comes on ; the patient is slow, yet 
somewhat jerky and indistinct in utterance; he can pronounce every 
letter perfectly, but fails to pronounce them accurately in combination, 
and slurs over his syllables. There is often, too, a manifest over-exer- 
tion of the muscles of the mouth and tongue in the effort to speak, and 
fatigue is soon experienced. In some cases (if such phenomena have 
not appeared earlier in the disease) paralysis of the third, fourth, sixth, 
portio dura, hypoglossal, or vagus of one or other side, comes on ; or 
double vision, impairment of vision, or amaurosis supervenes; or the 
patient grows absolutely deaf ; or he becomes subject to the various 
forms of pain which have been already described; while, on the other 
hand, if these have previously existed, they may disappear. Further, 
he may now be liable to severe and continuous aching pains in the fore- 
head and back of the head, along the spine, and in the trunk and ex- 
tremities, in connection with which, as with the earlier neuralgic pains, 
cutaneous eruptions may appear temporarily ; or he may, late in the 
disease, suffer from retention or incontinence of urine, and equivalent 
conditions affecting the rectum ; and generally he loses sooner or later 
all sexual desire and power. Occasionally, in the far-advanced stages 
of the disease, rigidity, contraction, and wasting of muscles come on : 
complications which are obviously due to the extension of disease from 
the posterior columns to the lateral columns and to the anterior cornua. 

Locomotor ataxy does not always involve the opposite limbs sym- 
metrically ; it often commences earlier in one leg than the other, and 



938 



DISEASES OF THE NERVOUS SYSTEM. 



invades one arm in advance of its fellow ; and in the subsequent prog- 
ress of the disease the legs or arms may continue to be unequally 
affected. The course, too, of the disease is very various. Sometimes 
the symptoms arise and succeed one another so rapidly that the patient 
becomes bed-ridden at the end of a few months. But much more 
commonly the successive phenomena are slowly and irregularly evolved, 
periods of apparent amendment from time to time intervene, and ten, 
twenty, or thirty years may elapse before the disease attains its full 
development. It is more than doubtful if absolute restoration to health 
ever takes place when the clinical phenomena are so fully declared as 
to render diagnosis clear. It is not, however, doubtful that many per- 
sons do experience great amelioration of their symptoms, and that such 
amelioration is sometimes of long duration. Occasionally, indeed, the 
course of the disease appears to be permanently arrested. In the vast 
majority of cases, however, the progress of the patient is, excepting for 
occasional interruptions, uniformly from bad to worse until death ends 
the scene. The causes of death are various. Generally it is due to 
some intercurrent malady ; but it may be referable to implication of 
the muscles of deglutition and respiration, to secondary bladder and 
renal mischief, or to the formation of bedsores. 

Treatment. — When temporary improvement has occurred under our 
own observation, it has always seemed due simply to avoidance of 
over-exertion, to rest, to protection from cold and wet and other such 
adverse influences, to judicious dieting and good hours: in fact to care- 
ful attention to the general well-being of the bodily health. It is not 
clear that any remedy exerts any, even the slightest, direct influence 
over the course of the disease. Nitrate of silver has been strongly 
recommended, iodide of potassium has been employed, iron and other 
so-called nervine tonics are often called into requisition. For the relief 
of pain, sedatives, such as opium or belladonna, or local applications 
such as counter-irritants, frictions, and galvanism, may prove service- 
able ; and indeed it may be said generally that all complications and 
all discomforts arising in the course of the disease should if possible 
be relieved. As regards electricity, Duchenne observes that Faradiza- 
tion, or galvanism with intermittent current, is often serviceable both 
in relieving pain and restoring voluntary power to paralyzed motor 
muscles in the earliest stages of the disease. But, while not' forbidding 
their employment at a later period, he is evidently not sanguine as to 
the results which are then likely to be obtained. 

Glosso-Labio-Laryngeal Palsy. 

Definition. — This name has been given by Duchenne to a paralytic 
disorder due to an affection of the medulla oblongata (whence also it 
has been termed paralysie bulbaire) involving mainly the seventh, 
ninth, and spinal accessory nerves, and revealing itself during life by 
paralysis of the lips, tongue, soft palate, and larynx. 

Causation. — Its causes are as obscure as those of other affections of 
the same class. It has been referred to the effects of cold and moisture, 
and it has appeared to follow upon strong moral emotions. It seems 



GLOSSO-LABIO - LARYNGEAL PALSY. 



939 



to be a disease of adult life, and to affect women much more largely 
than men. 

Morbid Anatomy. — The essential lesions of this disease are identical, 
so far as regards their nature, with those of locomotor ataxy, lateral 
sclerosis, and the like. They affect, however, a different region. Post- 
mortem examinations conducted on patients dead of this affection have 
revealed sclerosis, with more or less atrophy, of the roots of the spinal 
accessory, hypoglossal, and facial nerves, and sometimes similar changes 
in the roots of the vagi, in the motor roots of the fifth pair, and in the 
anterior roots of several of the upper cervical nerves ; but they have 
also revealed (which is of still greater importance) that these changes 
in the nerves are secondary to pigmental atrophy of the large cells con- 
tained in the nerve-nuclei situated in the medulla oblongata, associated 
with more or less circumambient sclerosis. Certain phenomena in the 
clinical history of these cases, and the fact of the frequent supervention 
of the symptoms of glosso-labio-laryngeal palsy in the course of lateral 
sclerosis, render it probable that the disease, when occurring in the 
uncomplicated form, is often due less to a primary lesion of the nerve- 
nuclei than to their secondary implication in the course of some sclerotic 
change occupying the anterior pyramids. 

Symptoms and Progress. — In the larger number of uncomplicated 
cases of glosso-labio-laryngeal palsy the symptoms of the disease come 
on quite gradually. The tongue usually first suffers. The patient 
experiences some difficulty in the articulation of his words, especially 
of those which need the special employment of the tip of the organ, 
and presently also more or less difficulty in mastication and deglutition; 
and he suffers from the accumulation of saliva in his mouth. The 
paralytic condition of the tongue gradually increases ; he has difficulty 
in protruding it and in drawing it in again, and ere long it lies motion- 
less or nearly so on the floor of the mouth, with its tip behind the an- 
terior incisors and its edge pressed and indented against the arch of the 
lower teeth. The tongue is sometimess reduced in size and wrinkled ; 
sometimes it feels large to the patient, and either retains its normal 
dimensions or exceeds them, Whilst this paralytic affection of the 
tongue is in progress, the muscles of the soft palate and arch of the 
fauces also become implicated, the patient's voice acquires a nasal 
quality, the difficulty of swallowing becomes aggravated, and his food 
is apt in the attempt to swallow to pass into his posterior nares. The 
arches of the palate when looked at, may occasionally be seen to be un- 
equal, with the uvula pointing to one side; but it is remarkable that 
even when the paralysis, so far as deglutition and enunciation are con- 
cerned, is complete, the velum can still be excited by local irritation to 
violent action. The lips are early involved : the orbicularis becomes 
enfeebled, the lips get large, the lower, one pendulous, and it soon be- 
comes difficult or impossible for the patient to close his mouth, to pre- 
vent the flow of saliva from it, to utter the labial consonants, to whistle 
or blow out a candle, or to perform any function requiring the use of 
the lips. According to Duchenne, it often happens that the quadratus 
menti and triangularis oris of each side become implicated, so that the 
angles of the mouth cannot be drawn down and extended; but he says 



940 



DISEASES OF THE NERVOUS SYSTEM. 



that the buccinators rarely suffer, and that the muscles of expression 
of the upper part of the face remain unaffected, and by their tonic 
contraction so act on the angles of the mouth as to cause the trans- 
verse elongation of the orifice, and at the same time so deepen and 
modify the direction of the naso-labial sulci as to impart to the patient's 
physiognomy the appearance of crying. Not unfrequently when a 
patient in this condition is made to laugh or cry the mouth becomes 
widely opened, and remains open until the upper lip is restored to its 
original position by means of the hand. The muscles by which the 
upward and downward movements of the lower jaw are effected for the 
most part retain their normal force, so that the patient can bite power- I 
fully up to the last. Nevertheless, difficulty of mastication, already 
extreme in consequence of the paralytic condition of the tongue, is 
enhanced by paralysis of the pterygoid muscles, which renders the 
movements necessary for trituration impossible. Sooner or later the 
muscles of the pharynx and those of the larynx share in the general 
paralytic affection, and hence the difficulty of deglutition becomes 
further aggravated. 

In the latter stages of the disease the patient ceases to utter any 
articulate sound, although a laryngeal grunt, indicative of the due 
action of the vocal cords, may attend each effort to speak. The saliva 
which is constantly dripping from his lips accumulates in his mouth, 
becomes sticky from long retention in it, and on opening his jaws, 
hangs in ropes and festoons between the opposite surfaces. His food 
collects in the sides of the mouth, or falls out through the open lips, 
and can only be made to reach the fauces either by throwing the 
head backwards or pushing the food onwards with the fingers. The 
pharyngeal stage of deglutition is equally difficult. Pultaceous matters 
are swallowed best ; but these have to be pushed into the back of the 
mouth in small quantities and with great care; and even then con- 
stantly cause choking, either finding their way into the windpipe, or 
into the nose, or being ejected by the spasmodic action of the pharyngeal 
muscles. The entrance of food into the larynx is mainly due to the 
failure of the tongue to descend with the epiglottis over the superior 
orifice of the larynx during the act of swallowing ; for it is only in 
somewhat rare cases that suppression of the laryngeal voice, indicative 
of paralysis of the laryngeal muscles, is observed. 

Sooner or later, however, the pneumogastric nerves become impli- 
cated, and then symptoms referable to the respiratory and circulatory 
organs are superadded. Attacks of difficulty of breathing, not due to 
the entrance of food or saliva into the windpipe, are now of frequent 
occurrence. They come on by day or night, and are often provoked 
by exertion. They do not appear to be connected necessarily either 
with pulmonary disease or with any paralytic condition of the ordinary 
respiratory muscles. Duchenne refers them to paralysis of the bron- 
chial muscles. There is no doubt, however, that catarrhal affections 
of the bronchial tubes are now exceedingly apt to arise, and that these, 
however slight they may be, greatly aggravate, if they do not induce, 
dyspnoeal attacks. Remarkable feebleness of circulation also super- 
venes at this period ; and especially the patient is liable to syncopal 



DISSEMINATED SCLEROSIS. 



941 



|l attacks, which sometimes accompany the fits of dyspnoea, and are 
attended with precordial anxiety, fear of death, and extreme feebleness 
and irregularity of the pulse, which is generally also much quickened. 

The phenomena above described are all unattended with febrile 
disturbance, loss of sensation, pain, giddiness, or any form of mental 
defect, the appetite continues good, the corporeal functions generally 

j are well performed, and the general system for the most part retains 

! its powers, excepting in so far as they may become impaired by the 
starvation which the difficulty of swallowing gradually induces. Hence 

! some patients who are far advanced in disease will continue to go about 
the house and even to take long walks. In many cases, however, 
towards the close of life they are confined to the chair or to bed. 

The course of glosso-labio-laryngeal palsy is generally rapid, and its 
end invariably death, which may come on within six months of its onset, 
and is very rarely indeed delayed beyond three years. The causes of 
death are: starvation from inability to take nourishment; asphyxia, 
from the impaction of a lump of solid food at the back of the throat, 
or from the repeated entrance of portions of food or saliva into the 
larynx; an attack of dyspnoea or of syncope; and lastly, pulmonary 
complications, bronchitis, and the like, which become especially dan- 
gerous when involvement of the respiratory muscles renders the dis- 
charge of bronchial accumulation difficult or impossible. 

It must be added that, although glosso-labio-laryngeal palsy con- 
forms in a large number of cases to the description which has just been 
given, it is not unfrequently a fragment, as it were, of some more 
widely diffused nervous disease. Thus, as is subsequently pointed 
out, it often forms one of the complications of disseminated sclerosis ; 
its supervention constitutes, almost without exception, the last stage of 
lateral sclerosis ; and, further, it is not uncommonly associated with 
progressive muscular atrophy, sometimes coming on late, sometimes 
constituting an early complication. The most important cases of the 
last group are those (and they are not very rare) in which the respira- 
tory muscles also waste. Again, it is important to recollect that groups 
of symptoms closely resembling those of glosso-labio-laryngeal palsy 
may be caused by effusions of blood into the pons or medulla oblongata, 
or by syphilitic or other disease of the same parts ; and may even arise 
in connection with the degenerative descending lesions connected with 
chronic forms of cerebral disease. 

Treatment. — Nothing that we are acquainted with is capable of ar- 
resting the course of this formidable malady. In the early stages 
galvanism may be applied to the enfeebled muscles, and possibly with 
slight temporary apparent benefit. In the later stages we must en- 
deavor to relieve symptoms ; and it may then be of service to feed the 
patient either by the aid of the stomach-pump, or per anum. 

Disseminated Sclerosis. [Multiple Sclerosis.) 

Definition. — " Sclerose en plaques disseminees " is the name which 
Charcot (to whom we are mainly indebted for its recognition and de- 
scription) has given to the affection which we here term disseminated 



942 



DISEASES OF THE NERVOUS SYSTEM. 



sclerosis. Dr. Moxon calls it insular sclerosis. It is characterized, 
post mortem, by the presence of a number of small roundish patches 
of sclerosis, scattered irregularly throughout the nervous centres ; 
clinically, by a variety of symptoms, among the most characteristic of 
which are tremblings of the head, neck, trunk, and limbs, coming on 
only when the muscles are being exerted, difficulty of speech, oscilla- 
tion of the eyeballs, gradually supervening paralysis, with contraction, 
mainly of the lower extremities, and some impairment of the mental 
functions. 

Causation. — Disseminated sclerosis is mainly a disease of adult life, 
usually coming on between the ages of twenty and twenty-five, rarely 
after thirty, but sometimes at the period of puberty. It is more com- 
mon in women than in men. It has been attributed to the same causes 
as those to which other forms of sclerosis have been attributed, namely, 
moral influences and exposure to wet and cold. Its advent has some- 
times been heralded by hysteria, neuralgia, or other nervous symptoms. 

Morbid Anatomy. — The sclerotic patches may appear in the cere- 
brum, cerebellum, pons, medulla, and spinal cord, either collectively or 
separately ; but generally are distributed in several of these organs at 
the same time. In the cerebrum they occupy mainly the neighborhood 
of the ventricles, and are found, therefore, in the corpus callosum, sep- 
tum lucidum, corpora striata, and optic thalami ; they occur also in the 
centrum ovale, but very rarely in the gray matter of the convolutions. 
In the cerebellum, their almost exclusive seat is the corpus dentatum. 
As regards the pons and the medulla oblongata, they may be either 
superficial or deepseated. In the former they affect mainly the ante- 
rior arid inferior aspect, extending thence to the cerebral peduncles and 
corpora albicantia; in the medulla, they occupy all parts indifferently, 
inclusive of the region forming the floor of the fourth ventricle. In 
the cord, as in the medulla, all parts are liable to be implicated. The 
cerebral and spinal nerves sometimes emerge, unaffected, from diseased 
tracts ; in other cases they are studded with similar morbid patches, or 
are involved generally. The cerebral nerves which chiefly thus suffer 
are the first, second, and fifth pairs. The patches of sclerosis vary in 
size, but are for the most part well defined, and of roundish form. 
They are dense, hard, slightly translucent, and of a grayish color, 
closely resembling that of the healthy gray matter of the brain. They 
sometimes project a little above the general level, sometimes are more 
or less obviously depressed below it. Microscopically they present all 
the ordinary characters of sclerosis ; and usually, according to Charcot, 
may be divided into three zones, of which the outermost represents the 
disease in its earliest phase, the innermost represents it in its most ad- 
vanced condition. In the outermost zone, the neuroglia is increased in 
amount and its nuclei in number, and the nerve-tubules are diminished 
in diameter at the expense of the white substance of Schwann ; in the 
next zone, the neuroglia has still further increased and has become dis- 
tinctly fibrillated, the nerves, more widely separated than they were, 
have become yet more reduced in size, and the white substance has al- 
most wholly disappeared, while the axis-cylinder has in many cases 
undergone enlargement ; in the central area, the overgrown neuroglia 



DISSEMINATED SCLEROSIS. 



943 



reigns paramount, the nerve-cells and nerve-tubules have for the most 
part disappeared, and those which still survive are far advanced in atro- 
phy. It may be added that the gradual disappearance of the white 
matter of Schwann involves the production of a large number of free 
oil-globules and of granule-cells, which stud the outer two zones, and 

| tend in them to accumulate within the lymphatic sheaths of the vessels ; 

| that the bloodvessels become increased in size, and the nuclei in their 
walls increased in number ; that the nerve-cells undergo pigmental 
atrophy, shrink, and finally disappear; and that corpora amylacea tend 

| to become developed in the course of the vessels. 

Symptoms and Progress. — It is clear that the symptoms to which 
patches of sclerosis may give rise must depend partly upon their size, 
partly on their situation, partly on their number. Thus it is obvious 
that if a patch of sclerosis should interrupt the continuity of the pos- 

I terior columns of the cord, symptoms more or less identical with those 
of locomotor ataxy would be developed ; that if it should involve one 
of the lateral columns, the symptoms referable to it would have more 

' or less resemblance to those characteristic of lateral sclerosis ; that if 
the anterior cornua should be implicated, more or less rapid wasting 
of certain muscles might be expected to follow ; that if the medulla 
oblongata should be its seat, some of the symptoms of bulbar pa- 
ralysis or of glosso-labio-laryngeal palsy would necessarily arise ; and 
that, if seated in the cerebrum, hemiplegia, convulsions, impairment 
of intelligence, or other of the various consequences of brain lesion, 
would almost certainly follow. It is obvious, further, that if many 
sclerotic patches should be distributed throughout the nervous centres, 
the consequences due severally to them would blend, as it were, into 
a common whole, producing collective symptoms of more or less com- 
plexity. 

It is, nevertheless, a fact that a large number of cases of disseminated 
sclerosis, in which the nervous centres are generally implicated, are 
attended with a group of symptoms which collectively afford almost 
positive proof of the nature of the malady which is in progress. [Ac- 
cording to Charcot and other writers, the disease is met with under 
three principal forms. In the first, or cerebral form, the sclerotic 
patches are limited to the brain, and the symptoms consequently are 
confined to the parts supplied by the cerebral nerves. We shall, there- 
fore, have, in addition to vertigo and mental disturbance, nystagmus 
and defect of speech particularly marked. In the second, or spinal 
form, the seat of the lesion is the cord, and the symptoms, therefore, 
will indicate their spinal origin. In this form tremblings of the limbs, 
followed by paresis and contraction, occur. In the third form, or cere- 
bro-spinal, the disease is disseminated through both brain and spinal 
cord, and we shall have the case presenting most of the features of the 
two other forms.] We will consider the more important of these 
symptoms successively. 

1. Rhythmical Tremors. — These constitute one of the most distinctive 
features of the disease. They are absent when the patient is asleep, 
they are absent also when he lies at rest, with his limbs and head sup- 
ported, but they come on whenever he makes any muscular effort, and 



I 



944 DISEASES OF THE NERVOUS SYSTEM. 

become more and more pronounced the greater and more sustained 
that effort is. When he raises his hand from the bedclothes, more or 
less violent convulsive movements seize his fingers, his hand, and his 
arm; if he attempt to raise his hand to his lips, these tremulous move- 
ments become aggravated ; and if, further, the muscular effort be ren- 
dered greater by his having to lift some heavy body, or something 
which requires care and precision in the handling, as, for instance, a 
glass of water, they are apt to become exceedingly tumultuous, and to 
increase in tumultuousness as the task set him approaches completion. 
Occasionally they are induced, when the arm is apparently at rest, by 
the nervous efforts of the patient to keep it still. If he sit up unsup- 
ported, similar movements affect his trunk and his head and neck. If 
he endeavor to stand or to walk, they become universal, and the legs, 
arms, trunk, and head are violently agitated. It is not pretended that 
these tremulous movements are present in all cases of disseminated 
sclerosis, but they are present in the great majority of cases. Nor 
must it be assumed that, when present, they are always of general dis- 
tribution ; they may (for a time at least) be limited to one arm, or to 
both arms, or when present in both may affect them unequally, or the 
legs may chiefly suffer. Neither must it be supposed that they are 
present during the whole course of the malady. Rhythmical trembling 
is rarely one of the earliest symptoms of the disease, but it usually 
comes on before long, and then invades the various parts slowly and 
irregularly, and it disappears as the patient becomes more and more 
enfeebled, and especially when paralysis supervenes. The movements 
are peculiar; they are rhythmical, and yet there is some degree of irregu- 
larity both in the extent of the successive vibrations and in the inter- 
vals which separate them. They have some resemblance to those of 
paralysis agitans, but in the latter the vibrations are less ample, more 
rapid, and more regular; moreover, they occur when the patient is at 
rest, and they rarely, if ever, directly implicate the head and neck. 
They have a greater resemblance still to those of chorea, but they are 
less wanton, less violent, and altogether more rhythmical than these 
latter are, and further, the vibrations in sclerosis take the direction of 
the general movement of the limb or part which is engaged in move- 
ment. It must not, however, be forgotten that tremulous movements, 
un distinguishable from those of sclerosis, may attend various other 
affections, and especially chronic mercurial poisoning, chronic cervical 
meningitis, and sclerosis of the lateral columns. 

2. Affections of the Eyes. — Double vision is a not uncommon symp- 
tom of the earlier stages of sclerosis, as it also is of locomotor ataxy, 
but is for the most part transitory and unimportant. Indistinctness of 
vision is a much more frequent phenomenon, and is generally perma- 
nent, but rarely ends in blindness. It is often present when no signs 
whatever of disease can be detected with the ophthalmoscope. But 
sometimes more or less advanced atrophy of the optic disk is present, 
which becomes complete in cases of total blindness. Nystagmus is a 
symptom of considerable importance, and is present in about half the 
total number of cases; it consists in consensual small oscillations of the 
eyeballs, which in slightly advanced cases maybe apparent only at the 



DISSEMINATED SCLEROSIS. 



945 



moment when the patient endeavors to fix his glance upon some fresh 
object, but they are generally constant, although aggravated by volun- 
tary movements of the eyeballs. They cease when the patient is 
asleep, or when his eyes are shut in repose. Nystagmus is rarely 
present in locomotor ataxy. 

3. Defect of Speech. — This is nearly constant. In well-marked cases 
the utterance is slow and drawling. The words (to use Charcot's ex- 
pression) are "scanned," as it were, there is a pause after each syllable, 
and the syllables themselves are slowly evolved. Moreover, they are 
imperfectly pronounced, certain letters or difficult combinations of let- 
ters being slurred, and sometimes to such a degree that speech becomes 
unintelligible. Further, the lips and tongue are often tremulous, the 
lips tremble previous to the utterance of articulate sounds, and during 
the couse of utterance, and the tongue when it is protruded is in con- 
stant fibrillar movement. This tremulousness of the organs of speech 
adds to the difficulty of articulation, and imparts to it a peculiar tremu- 
lousness or uncertainty. A very similar defect of speech is apt to 
accompany locomotor ataxy, but in that case the tremulousness of the 
lips and tongue is absent, and (at least according to our observation) 
the muscular efforts to utter articulate sounds are unnecessarily violent. 

4. Vertigo is an early symptom in about three-fourths of the total 
number of cases. It is mostly gyratory, generally comes on in parox- 
ysms of short duration, but is sometimes almost continuous. It often 
interferes seriously with locomotion. The presence of nystagmus is 
also a cause of vertiginous sensation, the oscillations which take place 
in the eyeballs being referred by the patient to the objects which are 
figured on the retinse. Vertigo is not common either in tabes or in 
paralysis agitans. 

5. Paresis of the limbs, and more especially of the lower extremities, 
comes on at an early stage of the disease. It generally commences in 
one leg. This feels weak and heavy, and drags in walking, but there 
are no movements indicative of incoordination. Soon the other leg 
becomes affected; but even then (so different from what occurs in 
tabetic patients) so long as he has sufficient strength to stand, he is 
capable of maintaining his equilibrium even when his eyes are shut. 
The weakness subsequently extends to the arms. This enfeeblement 
of the limbs gradually increases until it culminates in absolute motor 
paralysis : the convulsive oscillations to which the limbs are subject 
undergoing proportionate diminution until they finally cease. The 
paralysis which commences in the lower limbs becomes as a rule com- 
plete in them while the arms are yet comparatively little involved. 
The patient not unfrequently complains of some tingling and numb- 
ness, but there is rarely if ever any obvious impairment of cutaneous 
sensibility. Moreover, the muscular sense remains unaffected, so that 
he recognizes exactly the position of objects and the amount of force 
necessary to accomplish various voluntary movements. There is no 
paralysis of the bladder or rectum ; the affected muscles retain their 
form, bulk, and tonicity, and reflex and electrical contractility are un- 
impaired. It must be added that the paretic condition of the limbs is 
liable to remissions. 

60 



9-16 



DISEASES OF THE NERVOUS SYSTEM. 



I 



6. Contraction of Limbs. — At some period or other in the course of 
the paretic symptoms, the lower extremities, either spontaneously or 
under various forms of excitement, become suddenly stiffened in ex- 
tension, and pressed one against the other. These attacks may last 
some hours, or even some days, and are at first separated from one 
another by comparatively long intervals. But by degrees the intervals 
shorten, and at length ceasing, the rigidity of the muscles becomes 
permanent. At this period the thighs are extended on the trunk, the 
legs on the thighs, the feet on the legs, and the members lie in close 
apposition and cannot be separated. Sometimes the flexors overcome 
the extensors, and the limbs are flexed at all the joints. Occasionally, 
but at*a later period, the arms become rigid and pressed against the 
sides of the body. At this time violent tremblings, lasting for a few 
minutes or even longer, are apt to arise in the stiffened limbs. These 
sometimes seem to come on spontaneously, but may be excited by ex- 
posure to cold, or by pricking, tickling, galvanism, or other forms of 
irritation, and may extend from the limb in which they w^ere first in- 
duced to the opposite limb, and even cause general trembling of the 
body. They may be at once stopped, according to Brown-Sequard, by 
forcibly flexing the great toe. This stiffening of the limbs may be 
developed while their movements are still in some degree under the 
control of the patient, and does not therefore necessarily incapacitate 
him from walking with assistance. 

7. Expression and Mental Condition. — During the course of the dis- 
ease a marked change in the expression is apt to come on. The patient's 
glance is vague and uncertain, his lips pendulous and apart, his general 
aspect sad, weak, or fatuous. At the same time there is some change 
in his mental condition ; the memory fails, the conceptions are slow, 
and the intellectual and affective faculties generally impaired. He is 
stupidly indifferent to all that goes on about him, and is apt to laugh 
or cry without occasion. Sometimes he becomes maniacal or demented. 

One or more of the symptoms which have just been enumerated may 
fail in a greater or less degree in certain cases. But, on the other hand, 
additional phenomena are not unfrequently superadded. We have 
already suggested as possible complications certain phenomena which 
actually do not unfrequently present themselves, namely, the superven- 
tion in the course of the disease of incoordination of the movements 
of the lower extremities ; of wasting of certain of the voluntary muscles ; 
and of difficulties of deglutition, respiration, and circulation, indicative 
of involvement of the medulla oblongata. But, further, apoplectiform 
attacks are not unfrequent. These may come on without warning, or 
may be preceded by rapid failure of the mental faculties. They recur 
as a rule several times at irregular and long intervals. They are often 
attended with convulsions, which are usually unilateral, or with hemi- 
plegia, associated sometimes with flaccidity, sometimes with rigidity of 
the paralyzed muscles. In these attacks the pulse becomes greatly 
accelerated, and the temperature of the internal parts rapidly rises, so 
that probably in the course of the first few hours it mounts to 102°, and 
within twenty-four hours to as much as 104°. If the case is about to 
prove fatal, the temperature may reach 108° or 109°. In these cases 



i 



DISSEMINATED SCLEROSIS. 



947 



bedsores also are apt to form with great rapidity upon the sacral region. 
These apoplectiform attacks (which are not peculiar to disseminated 
sclerosis, but occur equally in cases of general paralysis and of tumors 
in the brain, and in cases in which embolic softenings or apoplectic 
effusions have left chronic lesions behind them) are distinguishable from 
those due to sudden hemorrhagic effusion by the fact of this sudden 
and rapid rise of temperature. 

Charcot divides the clinical history of cases of disseminated sclerosis 
into three periods. The first extends from the first appearance of symp- 
toms up to the supervention of rigidity of the limbs. The second in- 
cludes all that time subsequent to the first appearance of rigidity dur- 
ing which the patient's symptoms undergo gradual aggravation, but 
during which the organic functions as yet maintain their integrity. 
The third commences with the failure of the nutritive functions. 

First Period. — The mode of invasion is various. Sometimes the 
disease commences with symptoms referable to the brain, such as ver- 
tigo, or diplopia, followed soon by embarrassment of speech and nystag- 
mus. More commonly the first symptoms complained of are referable 
to the spine, especially weakness of the lower extremities, which may 
continue for months or even for years before it becomes complicated 
with other phenomena. This weakness is liable to remissions, and is 
usually attended with pain, loss or impairment of sensation, or diffi- 
culty of micturition or defecation. It presents nothing by which it can 
be distinguished as belonging to disseminated sclerosis unless or until 
it becomes associated with trembling or cerebral phenomena. Rarely 
the disease commences with symptoms like those which usher in loco- 
motor ataxy. The early progress of the disease is usually slow, but 
now and then the symptoms appear and follow on one another with 
great rapidity. The contraction of the limbs, the supervention of which 
terminates this stage, does not usually show itself till after the lapse of 
two, four, or even six years. 

Second Period. — This is usually of long duration. During it all the 
characteristic symptoms of the disease are present and undergo gradual 
aggravation, until the patient becomes utterly helpless and confined to 
his chamber or to his bed. 

The third period comes on with progressive weakening of the organic 
functions. The appetite fails, the patient is liable to diarrhoea. At 
the same time some of the symptoms proper to the disease come into 
special relief. The intelligence fails; the patient becomes, perhaps, 
fatuous ; the sphincters cease to act, and the evacuations are all passed 
unconsciously; the bladder becomes inflamed, and bedsores form. At 
this time, also, various intercurrent maladies are apt to come on, such 
as pneumonia or dysentery, or difficulty of deglutition, with other signs 
of involvement of the medulla oblongata. 

The duration of the cerebro-spinal form of the disease usually varies 
between six and ten years. If the cord qnly be affected, life may be 
prolonged for twenty years or more. The causes of death are numer- 
ous ; among the more important may be enumerated apoplectic attacks, 
the consequences of affection of the medulla, pneumonia and other in- 



948 



DISEASES OF THE NERVOUS SYSTEM. 



tercurrent disorders, inflammation of the bladder, bedsores, and de- 
bility from failure of the nutritive powers. 

Treatment. — This appears always to have failed. Charcot observes 
that both strychnine and nitrate of silver have served for a time to 
check the trembling of the muscles, but have had no permanent good 
effect. Arsenic, belladonna, ergot of rye, and bromide of potassium 
have all been used at various times, but without obvious beneficial re- 
suits. Little that is favorable can be said even of hydropathic treat- 
ment, or of Faradization, or of the use of the continuous galvanic cur- 
rent. [In one case slight improvement followed upon long-continued 
rest in bed ? and the use of small doses of bichloride of mercury.] 



PARALYSIS AGITANS. 

Definition. — This is a disorder mainly of advanced life and of chronic 
progress, characterized especially by trembling of the limbs arising in- 
dependently of voluntary movements, and for the most part sparing 
the head and neck. The patient in an advanced stage is, without ver- 
tigo, unable to maintain his equilibrium when walking. 

Causation. — The causes of paralysis agitans are various. It would 
seem to be not unfrequently brought on more or less suddenly by vio- 
lent emotion, terror, grief, rage, and the like. It is often referred, and 
probably with truth, to long-continued exposure to cold and wet. And 
it is asserted that it is occasionally traceable to wounds or bruises in- 
volving peripheral nerves ; in favor of which statement is the fact that 
severe neuralgic pains referable to such injuries have been succeeded 
by trembling of the parts involved, and subsequently by the general 
phenomena of paralysis agitans. There is no proof that the disease is 
in any degree hereditary. Neither does it belong to one sex more 
than to the other. It is for the most part a malady of advanced life, 
usually first making its appearance after the age of forty. It may, 
however, occur at an earlier period, and cases are on record in which it 
has commenced at twenty or even sixteen. 

Morbid Anatomy. — Of the condition of the nervous system in this 
affection nothing definite is known. Previously to Charcot's investi- 
gations, paralysis agitans and disseminated sclerosis were usually con- 
founded with one another, and the lesions of the latter disease were 
consequently regarded as having an important connection with the 
clinical phenomena of the malady now under consideration. In cases, 
however, of true paralysis agitans no constant lesions, sufficient at all 
events to explain the peculiarities of its symptoms, have yet been dis- 
covered. In some recent examinations of Charcot's, there were found 
obliteration of the central canal of the cord by increase of its epithe- 
lial lining, overgrowth of the nuclei which surround the ependyma, 
and marked pigmentation of' the nerve-cells, chiefly those of Clarke's 
posterior vesicular columns. It must be observed, however, that post- 
mortem examinations in cases of this disease are almost necessarily 



PARALYSIS AGITANS. 



949 



made on persons far advanced in life, in whom, therefore, on other 
grounds such changes as have been here referred to are likely to be 
met with. 

Symptoms and Progress. — The symptoms of paralysis agitans may 
come on gradually or suddenly. In the great majority of cases the 
onset of the disease is insidious. The part attacked is the hand or foot, 
or the thumb. If the hand be affected, its different segments oscillate 
on one another in a manner which is almost distinctive. The thumb 
moves on the other fingers as in the act of twisting wool or rolling a 
pencil, or as in the act of crumbling bread. If the affection involve 
also the rest of the upper extremity, these movements of the fingers are 
associated with similar rapid backward and forward movements of the 
hand as a whole on the forearm, and of the forearm on the upper arm. 
At this period of the disease the trembling is often transitory. It 
comes on occasionally only, and it may be at long intervals. It comes 
on, moreover, when it is least expected, when the patient is at complete 
rest, both mentally and bodily ; and it may be arrested by an effort of 
the will, and often ceases when he walks, or when he uses the affected 
part for writing, lifting a weight, or other purposes. The trembling 
may be confined for an indefinite time to the part first attacked. But 
it generally spreads sooner or later ; first, if a part only of a limb have 
been involved, to the rest of the limb, and subsequently, and often after 
longish intervals, to other limbs. It usually assumes in the first in- 
stance the hemiplegic form, affecting first the arm and then the leg of 
the same side, and extending later to the arm and leg of the opposite 
side. Sometimes it puts on the paraplegic character, spreading from 
one leg to the other, before the upper extremities become involved. It 
very rarely extends from one arm to the other, leaving the legs unaf- 
fected, or from the arm of one side to the leg of the opposite side. In 
some cases tremulousness is not the first symptom of which the patient 
complains. But its occurrence is preceded for a longer or shorter time 
either by a sense of profound fatigue, or by rheumatic or neuralgic 
pains referable to the limb or part of a limb in which convulsive 
movements subsequently manifest themselves. In rare instances the 
affection comes on quite suddenly, with tremulousness either of a single 
limb or of all the limbs. Under these circumstances it may subside at 
the end of a few days. But other similar attacks are liable to follow 
at decreasing intervals, until ultimately the disease becomes established. 
The duration of the initial stage to which the above account refers va- 
ries usually from one to two or three years. 

When the paralysis agitans has attained its complete development, 
the trembling not only involves several limbs, and probably all of 
them, but is also (at all events in severe cases) almost incessant. It is 
liable, however, to remissions and exacerbations, which latter seem to 
be often induced by emotional disturbance or by muscular exertion, yet 
not unfrequently come on without obvious cause. Further, natural 
sleep, or that induced by chloroform, is always attended with entire 
cessation of the convulsive movements. It is at this period also that 
the trembling puts on its most distinctive character. It consists of in- 
voluntary rhythmical oscillations, which have little amplitude, follow 



950 



DISEASES OF THE NERVOUS SYSTEM. 



one another rapidly, and present considerable uniformity; and which, 
when the hand is involved, give to its different segments the aspect of 
being collectively engaged in the performance of some delicate process 
or operation. The head and neck remain as a rule free from convul- 
sion. So far indeed from being agitated, the muscles of the face are 
immovable, the look is fixed, and the features present a permanent 
aspect of sadness or hebetude. Nystagmus, so common in disseminated 
sclerosis, is absent here. The muscles of the jaw are also free from 
movement, but the tongue, when protruded, not unfrequently presents 
well-marked tremulousness. There is no real failure of language, but 
speech is slow, hesitating, laborious, as though the enunciation of each 
syllable were attended with considerable effort. It may, however, be- 
come tremulous in consequence of the transmission of the tremulousness 
of the limbs to the head and neck. Deglutition is performed without 
difficulty, but is perhaps somewhat slow ; and often in old cases saliva 
tends to accumulate in the mouth. Respiration does not suffer. 

A striking phenomenon of the disease, to which Charcot has espe- 
cially called attention, is rigidity of the muscles, which comes on for 
the most part late in the course of the malady : occasionally, however, 
at its commencement. It affects the muscles of the extremities, trunk, 
and neck. The supervention of this rigidity is attended with cramps 
followed by contraction, which is at first transitory, but after a time 
becomes persistent, though even then liable to exacerbations. The 
flexor muscles suffer in the chief degree. The rigidity and contraction 
becoming permanent give a peculiar aspect to the patient. The head 
is thrown strongly forwards and fixed in that position ; and the trunk, 
when the patient stands, is bent in the same direction. The elbows are 
separated a little from the trunk, the forearms are slightly flexed on the 
arms, and the hands on the forearms resting upon the waist. The 
hands, moreover, become more or less deformed ; usually the fingers are 
slightly flexed in mass at the metacarpo-phalangeal joints, with an in- 
clination to the ulnar side of the arm, and with the thumb resting 
against the forefinger as in the ordinary position for writing ; but in 
some cases the fingers, though substantially occupying the same position, 
are flexed at the proximal and distal joints, but extended at the middle 
joints. The rigidity of the lower limbs is such as sometimes to give 
the appearance of paraplegia with contraction ; the feet are occasionally 
in the position of talipes equino-varus, and the toes bent into the form 
of a claw. The patient, however, retains the power of voluntary move- 
ment, and the muscles are never thrown into the tetanic spasms which 
are so common in many spinal diseases. 

The difficulty of movement which characterizes patients suffering 
from shaking palsy is due no doubt in some degree to the muscular 
rigidity and contraction which have just been described. But it often 
manifests itself long before the rigidity has become particularly obvious 
and seems indeed referable in large measure to a remarkable slowness 
in the accomplishment of the movements which the will directs to be 
done. The same peculiarity attends speech. It would seem that un- 
wonted efforts are needed for the transmission of the motor impulses; 
and indeed the slightest movements are followed by extreme fatigue. 



PARALYSIS AGITANS. 



951 



This group of phenomena has been taken to imply the existence of true 
paralytic weakness. But it is not so, for on testing the strength of dif- 
ferent limbs by the aid of the dynamometer, it has been often found 

I (excepting in the case of patients in the last stage of the malady) that 
the muscular force is remarkably preserved ; and sometimes, indeed, 

! that the muscles of the most tremulous and apparently weakened limb 

j are really more powerful than those of its seemingly healthier fellow. 
The mode of walking so common in paralysis agitans, and so char- 
acteristic when present, is occasionally absent. The patient who pre- 

I sents it rises perhaps with difficulty from his seat, then he steadies him- 

I self for a few seconds, and at length, with his head and trunk in ad- 
vance, runs straight forward in spite of himself with rapid steps. He 

; appears to be losing his equilibrium, and running forward to regain it, 
and not unfrequently falls. down. This difficulty of maintaining his 

1 balance in walking is not wholly due to the position which his body 
generally assumes, for it may occur while yet the patient is capable of 
retaining the erect posture; and, further, in some cases the patient has 
a tendency to fall or run backwards even when his body is bent for- 
wards. Neither is it connected with the presence of vertigo, for the 
patient does not as a rule suffer from this sensation. 

Various other symptoms besides those which have been enumerated 
complicate the course of paralysis agitans. Patients usually complain 
of a sense of persistent tension or traction in the affected muscles, or 
of cramps; they experience a feeling of prostration or of utter fatigue 
which especially comes on after fits of trembling; or they are the vic- 
tims of an undefinable malaise or fidgetiness. They want incessantly 
to shift their position, and if they be not assisted in their desire their 
sufferings become unendurable. They suffer most in this respect at 
night and when in bed. Another cause of suffering is an habitual sen- 
sation of excessive heat, referred mainly to the epigastrium and back, 
but not limited to these situations. It varies in intensity, and is usually 
most severe after the occurrence of a paroxysm of trembling. It is not 
attended with any actual elevation of temperature. Cutaneous sensi- 
bility is in no degree affected. The patient retains his mental faculties 
and the power over his rectum and bladder. 

The final stage of the disease supervenes for the most part at the end 
of some years. It is indicated by aggravation of the difficulty of 
movement, the patient being consequently compelled to keep his room 
or his bed ; by failure of nutrition, in which the muscles chiefly suffer, 
occasionally becoming fatty ; by impairment of intelligence and of 
memory ; by general prostration, and by the formation of bedsores. 
At this time the convulsive movements not unfrequently cease. Death 
results sometimes from gradual asthenia; more commonly from the 
supervention of some other disorder, especially pneumonia. The dura- 
tion of the disease may extend to twenty or thirty years. 

Treatment. — All forms of treatment have been employed, but for the 
most part with little success. Among the medicines which have been 
recommended may be named iron, nitrate of silver, chloride of barium, 
arsenic, zinc, strychnia, ergot of rye, belladonna, opium, hyoscyamus, 
and Calabar bean. Of these iron is advocated by Elliotson, and has 



952 



DISEASES OF THE NERVOUS SYSTEM. 



perhaps been instrumental in improving the general health of patients; 
and strychnia has been lauded by Trousseau, but seems to have been 
found injurious by Charcot. The only one of the sedative drugs which 
the latter authority thinks serviceable is hyoscyamus, and this effects 
no permanent improvement. Warm baths, cold baths, and shower 
baths are also sometimes of temporary service. Electricity has been 
largely employed, but the only form which seems to have been of real 
efficacy is the constant current. Some cases of recovery under its use 
have been recorded. It must not, however, be forgotten that some 
cases which have not advanced beyond the early stage get well sponta- 
neously. On the other hand, this fact justifies the hope of benefit from 
judicious treatment. Hygienic measures should never be neglected. 



MORBID GROWTHS. ANEURISMS. ENTOZOA. 

Various forms of adventitious growths affect the nervous centres or 
the structures which are in relation with them. It is quite impossible, 
however, to distinguish them from one another during life by reference 
simply to the nervous symptoms which they induce, and it is needless, 
therefore, for clinical purposes, to discuss each variety separately. It 
will hence be convenient to commence with a brief statement of some 
of the most striking of the pathological phenomena which the more 
important forms of growth present ; and then to discuss the clinical 
history of such tumors as a whole. 

Morbid Anatomy. — 1. Tubercle. In a strictly scientific arrangement 
of disease, we ought of course to include under this head miliary tuber- 
cles of the pia mater. We have, however, considered these elsewhere 
in association with meningitis, which they generally induce, and inde- 
pendently of which they rarely, if ever, cause symptoms. The variety 
of tubercle which we have now specially to consider is that which orig- 
inates within the nervous substance and forms tumors there varying 
from the size of (say) a pinVhead to that of a fowl's egg. They are 
well-defined, rounded, or lobulated masses, opaque, of a yellowish or 
greenish tinge, with much of the consistence and aspect of cheese. They 
rarely, if ever, break down into cavities, although they may become 
disintegrated at points; and almost without exception correspond to 
the description usually given of typical yellow or crude tubercle. They 
are, however, made up of an aggregation of smaller masses, and differ 
in no important respect from the tubercular aggregates which in cases 
of tubercular meningitis are found along the vessels or in the depths 
of the sulci, and are the result of the coalescence of miliary tubercles. 
They may be solitary, or may exist in large numbers ; and they may 
occur in any portion of the nervous centres, involving, however, by 
preference the gray matter both of the brain and cord. No doubt, from 
their large size, the cerebral lobes are pre-eminently liable to suffer. 
But tubercles have also a remarkable aptitude to form within the sub- 
stance of the cerebellum ; and then (according to Andral) in the ascend- 



MORBID GROWTHS. 



953 



ing order of frequency within the pons, the medulla oblongata, the 
spinal cord, the peduncles of the cerebrum and cerebellum, the optic 
thalami, and the corpora striata. They are much more common in the 
upper part of the cord than in the lower part. Tubercular tumors of 
the brain appear to be more common in boys than in girls, and are 
rarely met with either in adults or in children under two years of age. 
I They occur most commonly between the ages of three and seven. Tu- 
| bercle of the nervous centres is always associated with tubercle in other 
j parts, though not always secondary to it. It must be added that, 
i although there is no necessary connection between them, tubercular 
meningitis sometimes supervenes on the presence of tubercular masses 
of old date in the substance of the brain. 

2. Syphilis. — The ordinary seat of intracranial syphilis is the dura 
mater. The disease may involve the outer aspect of that membrane, 
! in which case it is usually associated with disease of the bones of the 
skull, and affects the brain mainly by pressure. Or it may involve 
j the substance of the membrane or its inner aspect, leading to the de- 
velopment of hard dense gummata, which may be solitary or scattered, 
or diffused over a considerable extent of surface, and may vary in- 
dividually from the size of a hazelnut downwards. They tend gradu- 
ally to involve the contiguous structures. The visceral arachnoid be- 
comes adherent to them, and not unfrequently similar growths then 
develop in the subarachnoid tissue and pia mater. Subsequently the 
subjacent brain suffers, becoming first indurated, and then either 
softened or the seat of gummatous growths. The parts of the dura 
mater which are most commonly affected are those corresponding to 
the convexity of the hemispheres, and those in relation with the an- 
terior and under surface of the brain, more especially in the neighbor- 
hood of the sella turcica, whence the disease may spread to the surface 
of the petrous portions of the temporal bones and to the tentorium 
cerebelli. 

Gummatous tumors originating in the pia mater or in the substance 
of the brain are much less common than the last, and as a rule they 
are softer and more transparent and jelly-like ; they are usually of 
small size, but may attain the bulk of a hen's egg. Those which are 
developed primarily from the pia mater affect mainly the under aspect 
of the brain, more especially from the optic commissure in front to the 
pons behind, and from the back of the pons to the cerebellar pedun- 
cles. These, too, are the situations in which they attain their greatest 
bulk. Tumors of the substance of the brain arise chiefly in the hemi- 
spheres, and the larger ganglionic masses, more especially the optic 
thalami. After these parts they affect mainly the pons Varolii and 
the cerebral and cerebellar peduncles. 

It is important to note that syphilitic disease, whether of the dura 
mater, pia mater, or nervous tissue, has a marked tendency to affect 
the parts at the base of the brain, and consequently to implicate the 
nerves there situated. It must be added that, although there are good 
clinical reasons for believing that the cord and its membranes are not 
unfrequently the seat of this disease, there are but few published cases 
in which the diagnosis has been verified by post-mortem examination. 



95i 



DISEASES OF THE NERVOUS SYSTEM. 



It is not uncommon for the cerebral arteries in connection with ' 
syphilitic growths to become obstructed with thrombi ; farther, it not 
unfrequently happens, in cases of secondary or tertiary syphilis, that, 
independently of the formation of gummata, the walls of certain of the 
arteries at the base of the brain become thickened, indurated, and 
translucent, apparently from hyperplastic changes, and the channels 
subsequently obstructed, partly from this thickening of the walls, 
partly from thrombosis. 

3. With respect to other neoplastic formations, notwithstanding the 
importance and frequency of some of them, we need not, for many 
reasons, go into much detail. They are mainly the following : fibroma, 
psammoma, melanoma, and cholesteatoma (to which, on account either 
of their rarity or insignificance in a clinical sense, we shall make no 
further reference), and myxoma, glioma, sarcoma, and cancer. 

(a) Myxomatous tumors are not altogether unfrequent. They some- 
times originate in the membranes of the brain or cord, sometimes in 
the cerebral substance. Their most common seat, however, is the cere- 
bral hemispheres, where they form transparent gelatinous growths, 
which often become cystic, and tend to acquire large dimensions. 
They may attain the size of a man's fist. 

(b) Gliomatous tumors, again, are not unfrequent, and, indeed, are 
almost special to the nervous centres. They are grayish or pinkish in 
tint, translucent and highly vascular, infiltrate, as it were, the tissues 
in which they are found, and blend insensibly with them at their 
edges. Moreover, though varying somewhat in color, transparency, 
and density, they have a considerable resemblance to the gray matter 
of the nervous centres. There are two forms of glioma, the one hard, 
the other soft. The former has a considerable anatomical resemblance 
to simply sclerosed tissue; the latter, which is the more common, 
blends on the one hand with myxoma, on the other with small round- 
celled sarcoma. Gliomatous tumors of minute size sometimes stud the 
ependyma of the ventricles. They are usually found, however, in the 
substance of the hemispheres, more especially in their posterior lobes 
and in their upper and lateral parts. They may be met with, how- 
ever, elsewhere in the nervous centres, and even in the spinal cord. 
They are for the most part solitary, of slow growth, and apt to attain 
a large size : that, for example, of the fist, or even of a foetal head. 
Owing to the great vascularity of the soft form of the disease, its 
tumors are liable to attacks of congestion, and also to more or less 
abundant extravasation of blood into their interior. 

(c) Sarcomatous tumors occur both in the dura mater of the brain 
and cord, and in the substance of these centres. They vary widely in 
their microscopical structure and in their aspect and rapidity of growth. 
Bat they may be divided roughly into two forms — hard and soft. The 
former has some resemblance to fibroma, the latter is usually more or 
less translucent, white, or gray, vascular, and, from its general resem- 
blance to brain-substance, has been termed in other organs than the 
brain, cerebriform. Sarcoma of the cerebral dura mater generally 
occurs at the base, in the neighborhood of the sella turcica or petrous 
bones ; that of the theca vertebralis affects no special seat. Sarcoma 



MORBID GROWTHS. 



955 



i originating in the nervous tissue is usually of the soft form, is gener- 
j ally solitary, and may grow to a large size. In the brain its usual 
! seats are, not the hemispheres, but the optic thalami, corpora striata, 
I corpora quadrigemina, pons, cerebral peduncles, and cerebellum. It 
I is only occasionally met with in the substance of the cord. Sarcoma 
! originating in the brain-substance is rarely, if ever, malignant ; the 
I solitary tumors, therefore, which have just been considered, are not as- 
| sociated with the presence of similar tumors in other parts. On the 
i other hand, it must not be forgotten that malignant sarcomas (melanotic 
I and other) of other organs are apt to be attended with multiple secon- 
dary tumors in the substance of the brain. Primary sarcoma of the 
brain is mostly a disease of early childhood. 

(d) Carcinoma of the nervous centres, and of the parts about them, 
was formerly believed to be of common occurrence; but by all authors 
up to a very recent date, sarcoma, glioma, and probably other forms of 
tumors, were all regarded as varieties of carcinoma. Carcinoma, in 
the restricted sense of the term, rarely if ever originates in the brain 
or cord, and not often in the bones and soft parts immediately sur- 
rounding them. It not unfrequently, however, during the period of 
generalization, involves all these parts, and hence scirrhous, encepha- 
loid, and melanotic tumors are not uncommon as secondary occurrences 
in the brain or cord, and in the membranes and bony parietes of these 
organs. Carcinomatous tumors are therefore generally multiple, and 
probably rarely reach a large size. Carcinoma of the skull, or of the 
vertebrae, or of the periosteum of these parts, is apt in its progress to 
reach the surface of the brain or cord, and to involve these organs 
either by pressure or by direct extension of disease ; it is especially 
apt, moreover, to constrict the bony channels by which the nerves 
escape, to implicate the nerves, and thus to compress and finally de- 
stroy them. 

4. Entozoa. — The only entozoa which infest the brain of man are 
the cysticercus cellulosse and the hydatid, (a) Although a consider- 
able number of cases of cysticerci in the nervous centres are on record, 
they are met with very rarely. The cysts, which are of the size of a 
pea or horse-bean, vary in number from one or two to one hundred or 
more, and they occupy either the subarachnoid tissue or some of the 
processes of the pia mater, such as the choroid plexuses, or the nervous 
parenchyma, In the last case they are most common in the cerebral 
hemispheres, but have been met with in the cerebellum, medulla ob- 
longata, and other parts. 

(b) Hydatids of the brain are rare. They are generally solitary, 
but occasionally a couple or more have been found in the same case. 
They are almost invariably barren. Their size varies ; but they not 
unfrequently attain a couple of inches in diameter before they cause 
death, and may reach a much larger size. They are generally met with 
in the substance of the cerebral hemispheres, but have been found in 
the cerebellum, and may exist elsewhere in the nervous parenchyma. 
They also affect the meninges, and have been discovered in the lateral 
ventricles and in the subarachnoid tissue of the cord. They rarely 
cause inflammatory changes in the tissues which surround them, or 



956 



DISEASES OF THE NERVOUS SYSTEM. 



other mischief beyond such as may arise from simple pressure. Neither 
do they appear ever to become the seat of suppuration. Hydatids of 
the brain are not unfrequently associated with hydatids in the liver or 
other organs. They are said to occur chiefly in persons between ten 
and twenty years of age. 

5. Aneurisms of the Arteries at the Base of the Brain. — We speak 
of these now only as tumors, and because from their bulk and situation 
they are exceedingly liable to interfere with the functions of important 
parts. They arise chiefly in the internal carotid arteries with their 
middle meningeal branches, and in the basilar ; but they are occasion- 
ally also found upon other vessels, such as the anterior and posterior 
cerebrals, the anterior and posterior communicating branches, and at 
the bifurcation of the basilar. An occasional seat also is that portion 
of the common carotid which lies within the cavernous sinus. They 
vary in size usually from that of a pea to that of a marble, but have 
been met with as large as a hen's egg. From their position they are 
liable to compress some of the nerves at the base of the brain, and 
to indent the surface of the brain itself. They usually occur in per- 
sons upwards of forty, but have been met with in such as have 
scarcely passed the age of puberty. Males are more liable to them, 
than females. 

Symptoms and Progress. — 1. Brain. The symptoms referable to 
tumors involving the brain present the greatest variety: a statement 
which is not likely to be disputed when one takes into consideration 
the various circumstances under which tumors arise, the differences of 
the progress of different forms of tumors, and the various parts of the 
surface or substance of the brain which they may chance to implicate. 
It is impossible, indeed, to draw up any scheme of symptoms generally 
applicable to cases of the kind; and we propose, therefore, to consider 
seriatim the more important symptoms which the presence of cerebral 
tumors may induce. 

Vertigo is rarely absent from some period or other in the progress 
of the case. Sometimes it is the first symptom of which the patient 
complains, and often it is the most constant. Headache is generally a 
prominent symptom. In some instances it is one of the earliest, in 
association with vertigo and occasional vomiting. It is often persistent, 
but liable to exacerbations, and sometimes only comes on at more or 
less irregular intervals. It may be little complained of, or even be 
wholly absent. It varies in character : is sometimes a sense of con- 
striction or of pressure, sometimes a feeling as though the head would 
burst, sometimes shooting, aching, or boring. It is referred to different 
parts in different cases : sometimes affects the vertex, sometimes the 
forehead, sometimes the occiput mainly; sometimes shoots through the 
ears or temples, in the latter case probably involving the eyeballs, and 
associated with more or less intolerance of light. The situation of the 
pain is no sure guide to the seat of disease ; nevertheless it may be 
observed that pain referred to the occiput and back of the neck is not 
unfrequently associated with the presence of disease in the posterior 
fossa of the skull. 

Vomiting is a common symptom of many cerebral diseases, and is 



MORBID GROWTHS. 



957 



often an early indication of the presence of cerebral tumors. Indeed, 
it is known, especially in reference to the tubercular tumors of children, 
that unaccountable vomiting is often the first warning of the affection 
which is in progress. The vomiting often comes on at irregular in- 
tervals without obvious cause, is not unfrequently attended with nausea 
or loss of appetite, and is generally associated with constipation. It 
may continue on and off during the whole of the patient's illness, but 
is mainly a symptom of the earlier stages. Slowness of pulse, with 
more or less irregularity, is of frequent occurrence, more especially 
during the period of invasion; subsequently also the same condition of 
pulse may prevail. But on the other hand it is then often of normal 
rate, or increased in frequency. 

Hemiplegia. — This condition is no doubt entirely absent in a large 
number of cases, and when present usually comes on insidiously during 
the later stages of the disease. There is, however, great variety as re- 
gards this symptom. In some instances almost the first occurrence 
indicative of disease is an apoplectic or epileptiform fit followed by 
hemiplegia. In some the attack of hemiplegia comes on suddenly in 
the course of other symptoms. And in either of these cases more or 
less complete recovery from the paralytic phenomena may ensue, to be 
followed by a relapse or by a series of recoveries and relapses. The 
hemiplegia generally follows the rule of ordinary hemiplegia in the 
fact that the arm is more affected than the leg, and the lower distribu- 
tion of the seventh nerve than the other motor nerves of the face. But 
occasionally the paralysis is slight or limited, and reveals itself only 
in the face or arm. It may or may not be associated with numbness, 
tingling, or anaesthesia of the paralyzed parts, or with hyperesthesia, 
tenderness, or pain. Rigidity and contraction of the affected limbs 
may supervene. 

Local paralyses are of very common occurrence, sometimes in asso- 
ciation with hemiplegia, sometimes independently of it. They are 
generally due, not as hemiplegia or hemianesthesia is, to disease in- 
volving the opposite corpus striatum or optic thalamus or cerebral 
hemisphere, but to direct implication by pressure or by involvement 
in the morbid process of the nuclei of origin of the affected nerves, or 
of the nerves themselves in some part of their course from these nuclei 
outwards. If, therefore, they be due to the same mass as causes hemi- 
plegia, they must occur on the opposite side of the body to the hemi- 
plegia. It need scarcely, however, be pointed out that more tumors 
than one are not unfrequently present, and that tumors of the crura 
cerebri, pons, or medulla, or growths in the neighborhood of the circle 
of Willis, may readily involve directly several nerves of either side, 
even when causing at the same time distinct hemiplegic phenomena. 
In some cases there is paralysis of one or both external recti, leading 
to single or double internal squint ; in some, paralysis of the whole or 
a portion of one of the third nerves, involving ptosis, with paralysis 
perhaps of the internal rectus and an outward squint; in some the 
portio dura suffers, and Bell's paralysis is the consequence, probably, 
however, associated with paralysis of the corresponding arch of the 
fauces ; in some, again, the hypoglossal becomes implicated. It is of 



958 



DISEASES OP THE NERVOUS SYSTEM. 



I 



some interest in reference to these local paralyses to bear in mind (as 1 
has already been pointed out) that, contrary to what occurs in ordinary 
hemiplegia, the electrical contractility of the affected muscles rapidly 
disappears, and acute wasting of muscles is also apt to ensue. 

Local Implication of Sensory Nerves. — The fifth nerve occasionally 
suffers, either generally or in some of its branches ; in some instances 
intense burning or neuralgic pains arise, in some tingling, numbness, 
or absolute anaesthesia. In the last case the surface of the eye, among 
other parts, becomes insensible, and consequently unconscious of irrita- 
tion and liable to get inflamed. Sometimes from implication of one or 
both of the olfactory nerves, or one or both of the gustatory nerves, 
the sense of smell or taste is lost on one or both sides. As regards the 
ears, there is not unfrequently more or less deafness, with buzzing, or 
rushing, or singing noises; and absolute deafness on one side may 
ensue. The most interesting and important complications, however, 
are those which involve the visual properties of the eye. We have 
alluded to the fact of the occasional occurrence of double vision and of 
intolerance of light. But, besides these phenomena, we often meet 
with more or less obscurity of vision, which may go on to complete 
blindness, in one or both eyes; hemiopia, the field of vision being 
eclipsed in the identical halves of both retina?; the appearance of 
muscse; and other visual derangements. The presence of cerebral 
tumors is, moreover, almost always associated with more or less well- 
marked optic neuritis, or that form of it to which Dr. Allbutt gives 
the name of " choked disk,' 7 and which may after a time be replaced 
by more or less atrophy of the optic disk. The same rules apply to 
these paralyses of sensory nerves that have been used in explanation 
of the paralyses of motor nerves: they are usually due to direct impli- 
cation of the nerves or of their nuclei, and are observed therefore on 
the same side of the face as the cerebral tumor which causes them ; and, 
further, the question whether they be dependent on these causes or on 
disease of the nervous centres above their special nuclei, can generally, 
in doubtful cases, be determined by the fact that in the former case no 
reflex phenomena can be excited, in the latter they may be pretty 
readily induced (M. Jaccoud). If, for example, the disease causing 
blindness be in the optic nerve, the pupil will be dilated, and will not 
contract under the influence of light, while, if it be situated above the 
corpora geniculata, the patient, though equally blind, will have free 
action of the pupil under the influence of the ordinary stimuli. It 
need scarcely be added that the optic nerves are peculiar in decussating 
below their nuclei of origin, and that disease of either optic tract or 
either optic nucleus involves the production of hemiopia. 

We may add that these various local sensory and motor affections 
may come on at any period of the disease ; that they are liable to ap- 
pear and disappear before they become permanent ; and that they tend 
to increase in degree and in number with the advance of the 'disease. 

Intellectual and Emotional Disorders. — These, it need scarcely be said, 
present great variety. In some cases one of the earliest indications of 
cerebral, disease is the occurrence of attacks, sometimes momentary, of 
incoherence, delirium, failure of speech, or loss of consciousness asso- 



MORBID GROWTHS. 



959 



ciated or not with some partial convulsive movement or paralysis ; in 
some a more or less violent epileptiform convulsion, limited probably 
to a few muscles, or to a limb, or to one side of the body, and preceded 
or not by an aura ; in some an attack which may exactly simulate an 
hysterical fit ; in some an apoplectic seizure. Or such attacks may be 
delayed until a late period of the disease, and indeed may only occur 
as the immediate precursors of death. The attacks of incoherence, of 
momentary loss of consciousness, of hysteria-like fits, and of epilepti- 
form convulsions, may come on at long and irregular intervals, or they- 
may be very frequent, and indeed they may occur many times a day, 
and even in long-continued sequences. In a large proportion of cases 
the patient suffers from gradually increasing failure of memory and 
hebetude : he becomes aphasic, or incoherent, or fatuous, and under such 
circumstances possibly loses or fails to exert control over his evacua- 
tions; or he becomes delirious or maniacal; and further, associated 
with some of these mental derangements, we find him not unfrequently 
either given to boisterous laughter, or low-spirited and apt to cry. 

Obstruction of Venous Minuses. — Cerebral tumors occasionally cause 
obstruction either of the cavernous sinus or of the sinuses between this 
and the internal jugular vein; and as a consequence, the veins of the 
eyelids and of the corresponding side of the forehead become more or 
less obviously distended. Similar dilatation of veins sometimes occurs 
in these cases, even w T hen no obvious obstruction is present. 

Lastly, it may be pointed out that bedsores are often developed 
sooner or later — occasionally early in connection with the occurrence 
of irritative or inflammatory processes ; more frequently late, when the 
patient is bed-ridden, paralyzed, and fatuous. 

We repeat that the symptoms caused by the presence of cerebral 
tumors display at all stages the greatest diversity ; nevertheless, care- 
ful attention to all the phenomena which the patient presents will, in a 
very large number of cases, allow of a fairly accurate diagnosis being 
made. The onset of the disease may be gradual or sudden, and the 
symptoms which attend the onset may be of the most varied kind. The 
subsequent progress of the case is equally diverse ; sometimes the symp- 
toms progressively and rapidly increase until death takes place ; some- 
times, and indeed in the £reat majority of cases, the patient is liable to 
remissions of his symptoms, and to intervals, it may be, of apparent 
restoration to health. But in all cases such remissions become less and 
less marked with the advance of the disease, and at length continuous 
illness is established. The duration of life from the first development 
of symptoms differs largely ; sometimes the patient sinks at the end of 
a few weeks ; sometimes death is delayed for several years. It must 
be observed, however, that the commencement of symptoms cannot 
always be determined ; and this is especially the case when cerebral 
tumors complicate other diseases. The causes of death are various. In 
some cases the patient sinks from innutrition and the formation of bed- 
sores ; in some he is carried off in an attack of convulsions; in most, 
death is ushered in by coma. 

It is not always possible to distinguish the symptoms referable to 
cerebral tumors from those caused by other affections of the same parts ; 



960 



DISEASES OF THE NERVOUS SYSTEM. 



nor is it surprising, when we bear in mind that many other diseases 
occupy certain districts in the brain, which tumors may also occupy ; 
and that these as well as tumors are liable to be attended with more or 
less swelling, inflammation, or softening, and to produce symptoms both 
of a general and local character. Among the affections here referred 
to are apoplectic effusions, embolic softening, abscess of the brain, and 
chronic disease of the dura mater. 

The determination of the site of a tumor must rest upon a consid- 
eration of the various details of the paralytic and other phenomena 
which the patient presents. In many cases we may come to a fairly 
accurate conclusion on these points ; but it must not be forgotten that 
insuperable difficulties are often presented by the fact either that tumors 
are multiple, or that they occupy some tract within the hemispheres, or 
at their surface : lesions of which are not necessarily attended with 
hemiplegia or any specific nerve-lesions. 

The recognition of the nature of a tumor must depend partly on 
our knowledge of the circumstances under which certain forms of 
tumor are apt to arise, partly on our knowledge of the part of the 
brain which each variety of tumor is most prone to affect, and partly 
on the duration of the disease. Tubercle, for example, is limited for 
the most part to children ; the cerebral phenomena due to its presence 
are often remarkably slow in their evolution ; and the disease is gen- 
erally associated with tubercular disease elsewhere. Moreover, symp- 
toms of tubercular meningitis are apt to supervene. Syphilitic tumors 
occur in adults who have usually either a distinct history of having con- 
tracted a chancre, or obvious traces of constitutional syphilis. They 
tend, moreover, in a remarkable way to affect the under part of the 
brain, and to involve therefore the nerves there situated ; to cause 
cephalalgia, defect or loss of smell, hemiopia, paralysis of some of the 
orbital nerves, deafness, paralysis of the portio dura, bulbar palsy, and 
above all, perhaps, trigeminal neuralgia or paralysis, and, in connec- 
tion with these, the nutritive lesions, which have been previously de- 
scribed. Further, it must not be forgotten that syphilitic patients are 
(even in the secondary period) liable to have sudden thrombotic occlu- 
sion of cerebral arteries, and symptoms identical with those attending 
embolism. Secondary malignant growths wOuld be suspected if the 
patient were suffering also from a mediastinal tumor, or some form of 
malignant disease involving the skin, the bones, the mammae, the uterus, 
or other organs. The presence of hydatids might be surmised if there 
were a total absence of all constitutional symptoms or taint and of all 
indications of local inflammation or softening, if moreover the patient 
were young, and especially if a hydatid tumor were detected in the 
liver or some other accessible organ. The symptoms due to aneurisms 
are generally much more obscure than from the position of the tumors 
might have been supposed. Indeed, their presence is often not suspected 
until their rupture causes apoplectic phenomena and death. 

2. Spinal Cord. — Tumors involving the spinal cord, its membranes, 
or the nerves which spring from the cord, cause symptoms partly due 
to the compression or destruction which they effect upon the substance 



MORBID GROWTHS. 



961 



of the cord, partly due to involvement of the nerves, partly clue to local 
conditions of inflammation and the like. 

(a) Those which originate in the substance of the cord are attended 
with much the same symptoms as is compression of the cord connected 
with vertebral caries. They cause more or less complete paraplegia in 
the parts which derive their innervation from the portion of the cord 
situated below them; and the distribution and the character of this 
paralysis will obviously vary according as the tumor is situated higher 
or lower in the cord, or according to the tract which it primarily in- 
volves, and its horizontal extension. There are some points, however, 
in regard to these tumors, which it is well to remember : their pres- 
ence is rarely, if ever, attended with either central or peripheral pain ; 
they originate mainly in the gray matter, and hence both sensation and 
motion are as a rule early affected ; they commonly involve one side of 
the cord or some other limited portion of the cord, in the first instance, 
and hence induce irregular or cross paralysis, so that during the earlier 
period of their development there is very likely to be motor paralysis 
on the side of the lesion, and anaesthesia on the opposite side ; and the 
progress of the paraplegic symptoms is liable to remarkable remissions. 
It may be added that, owing to certain peculiarities as to their primary 
site, it is possible that their first symptoms may simulate those of loco- 
motor ataxy or those due to lateral sclerosis ; that they tend ultimately 
to produce absolute paraplegia; and that, wheresoever originating, 
they are liable to be followed by ascending and descending degenerative 
changes, and by spasms and contractions of the affected muscles, with 
more or less rapid wasting of some of them. 

(b) Tumors taking their origin in the meninges of the cord are apt 
at a very early period to implicate the sensory or motor roots of the 
nerves which are in relation with them. Hence arise, and sometimes 
before any paraplegic symptoms are developed, twitchings of certain 
muscles, followed by paresis, paralysis, and rapid wasting ; or burning 
or quasi-neuralgic pains referred to the peripheral distribution of one 
or more of these nerves (it may be in the first instance to a single 
spot) : pains which are subject to great variations, are often exceedingly 
intense, and are occasionally accompanied by cutaneous eruptions. The 
paraplegic symptoms which attend such cases are usually quite undis- 
tinguishable from those which follow on vertebral caries, and are (at 
all events in the first instance) due to compression of the cord alone. 
It is obvious that the distribution of the paralytic phenomena, and 
the order of their sequence will depend largely on the position of the 
tumor and the direction in which pressure on the cord is applied. 

(c) Tumors which are primarily developed in the tissues external 
to the membranes, more especially therefore aneurisms and malignant 
growths, usually involve the sensory and motor nerves in the neighbor- 
hood of their origin long before they involve the cord itself. These, 
far more than tumors originating in the meninges, are thus apt to 
induce severe sensory and motor troubles of limited distribution. The 
pain which they evoke is burning, wrenching, or crushing, constant, 
but liable to frequent exacerbations, which are often quite beyond en- 
durance, and during which the patient groans or shrieks with agony. 

61 



962 



DISEASES OF THE NERVOUS SYSTEM. 



It is often attended with great hyperesthesia of the surface of the 
affected parts, and after awhile probably followed by circumscribed 
anesthesia, and by bullous or erythematous eruptions. The motor 
troubles are mainly paresis, and rapid wasting and contraction of cer- 
tain groups of muscles. These phenomena occur with special intensity 
in cases of carcinoma involving the bodies of the vertebrae ; in which 
case, owing partly to the tendency of the affected bodies to collapse, 
partly to the tendency to the formation of outgrowths involving the 
nerves themselves, the various phenomena just considered are apt not 
only to be exceedingly acute, but to have a comparatively wide distri- 
bution. If, for example (as is most common) the disease be situated 
in the lumbar region, they probably implicate irregularly both lower 
extremities and the lower part of the abdominal surface as well. Phe- 
nomena due to compression of the cord come on (if they come on at all) 
at a later period. 

Assuming the presence of a tumor, its nature can only be determined 
in certain rare cases. If tubercle be ascertained to exist in other 
organs, we have some reason to suspect that associated paraplegic 
symptoms (if not due to vertebral caries) are due to a tubercular mass 
in the substance of the cord. If paraplegic symptoms come on during 
the reign of constitutional syphilis, we may have in that association a 
clue to the nature of its cause. If paraplegic symptoms be preceded 
by agonizing pain, such as has been above described, we have grounds 
to suspect the presence of some tumor involving the vertebrae; and if 
these symptoms come on in the course of mammary or abdominal can- 
cer, and especially if we find the spine presenting some localized 
obtuse bend in the neighborhood of the point from which pain radiates 
and paraplegic symptoms begin, we have confirmatory evidence of the 
strongest kind. 

Treatment. — The treatment of tumors, whether of the brain or cord, 
must be for the most part simply palliative. We should endeavor to 
relieve sickness by some of the various methods which are usually had 
recourse to for that purpose; to alleviate pain, either by the applica- 
tion of cooling lotions, or ice, or aconite, or belladonna, or other 
sedatives, to the seat of pain, or by the internal exhibition of sedatives 
or narcotics, especially of Indian hemp or opium. The subcutaneous 
injection of morphia is in many cases an invaluable mode of treatment. 
There are certain cases, however, in which treatment is of real value, 
either in arresting the progress of a tumor or in causing its removal. 
Tubercular masses are often of exceedingly slow growth, and may, in 
fact, remain quiescent for months or years. If we have reason to sus- 
pect the existence of such a tumor it is of course important to have re- 
course to iron, cod-liver oil, and other drugs and modes of treatment 
serviceable in tuberculosis. Tumors of syphilitic origin may often, if 
attacked early, be so far influenced by treatment that the patient be- 
comes practically restored to health ; and, even if complete restoration 
be not effected, great and permanent amendment may ensue. Iodide of 
potassium and mercury are the drugs specially indicated in these cases. 



CEREBRAL AND SPINAL HEMORRHAGE. 



963 



CEREBRAL AND SPINAL HAEMORRHAGE. {Apoplexy.) 

Causation. — Excepting those forms of hemorrhage (which have little 
clinical interest) occurring in the course of purpura, small-pox, and 
other specific disorders, and due to an abnormal condition of the blood, 
all haemorrhages within the skull or spinal canal are consequent on the 
rupture of bloodvessels. This rupture may be due to violence, as, for 
example, to blows on the head or spine, or to fracture of these parts, 
and may occur therefore at any age. Idiopathic hemorrhage, however, 
although it occasionally arises below the age of twenty, becomes com- 
mon only after forty, and from that time onwards its frequency in re- 
lation to the number of persons living at each successive period of life 
rapidly increases. Old age, therefore, has great influence in its causa- 
tion. But there are certain other conditions which are of more direct 
importance than even old age : these are the presence of chronic 
Bright' s disease, and that of degenerative affections of the arterial sys- 
tem. It is more common in men than in women. 

Morbid Anatomy. — Haemorrhage may occur either between the dura 
mater and the bone, within the cavity of the arachnoid, into the 
subarachnoid space, into the nervous substance, or, lastly, into the 
ventricles. 

1. Meninges. — The effusion of blood between the bone and dura 
mater is not uncommon in adults, especially as the consequence of a 
blow on the head or a fracture of the skull, and is usually immediately 
referable to laceration of the middle meningeal artery. The blood ac- 
cumulates, separating the dura mater from the bone in some limited 
area, and forming a convex protuberance, which displaces the cerebral 
surface in relation with it. If the patient survive, the blood under- 
goes those changes which are common to all such extravasations, and, 
after awhile, becomes absorbed. Haemorrhage external to the theca 
vertebralis is also mostly due to mechanical violence. It may, how- 
ever, be the consequence of the rupture of an aneurism of the aorta. 

Hemorrhagic accumulation in the cavity of the arachnoid is always 
referable to escape of blood either from the dura mater or from the 
subarachnoid tissue. If the dura mater be its source, it may either be 
a direct consequence of mechanical violence, or be derived from a patch 
of pachymeningitis, with hemorrhagic effusion between its lamine. 
If the subarachnoid tissue be its source, it may be due to any one of 
the causes, to be presently discussed, of effusion of blood into that 
tissue. The arachnoidean cavity appears to be a frequent seat of 
hemorrhagic effusion in newly-born children, the effusion in that case 
being probably due to the effect of violence in the process of being 
born. Blood escaping into this cavity readily diffuses itself through- 
out its whole extent. Here, as in other cases, if the patient live, the 
blood for the most part undergoes gradual absorption ; occasion- 
ally, however, it becomes converted after a time into a thin-walled cyst, 
full of thin serous fluid, and has then little or no tendency to undergo 
further change. 

Hemorrhagic effusion into the subarachnoid tissue is frequently due 



964 



DISEASES OF THE NERVOUS SYSTEM. 



to the rupture of an aneurism of one of the arteries at the base of the 
brain. It is then generally very abundant, and distends primarily all 
the lax portion of the tissue which abounds in this locality: encircling 
all the vessels and nerves and concealing them, together with the sur- 
face of the crura cerebri, pons, and adjoining portion of the medulla 
oblongata : and extending thence into the laminae of the velum inter- 
positum and the corresponding duplicatures connected with the fourth 
ventricle, along the fissures of Sylvius, and according to circumstances, 
over a greater or less extent of the surface of the hemispheres of the 
cerebrum and of the lobes of the cerebellum. Sometimes the blood 
escapes from a hemorrhagic cavity in the substance of the brain, which, 
approaching the surface of the organ, causes its laceration. This acci- 
dent is not uncommon in the neighborhood of the island of Reil, in 
which case the centre of the meningeal extravasation will be the recess 
at the bottom of which the island is situated ; it is apt to occur also 
when blood is effused into the pons or crus cerebri. Another cause of 
subarachnoid hemorrhage is punctiform extravasation, or extravasation 
from laceration, of some portion of the surface of the brain, such as is 
caused by contre-coup. Subarachnoid haemorrhage is occasionally also 
observed on the surface of the cord. 

2. Brain. — Haemorrhage into the substance of the brain may, especi- 
ally if it be into certain parts of the cortex, be due to laceration of the 
brain-substance from violence ; it is far more commonly, however, the 
consequence of the rupture of diseased vessels or of the miliary aneur- 
isms which Charcot and Bouchard have shown to be common in cases 
of cerebral haemorrhage and in the brains of old people, especially 
in the optic thalami, corpora striata, cerebral convolutions and pia 
mater. The vessels in which rupture takes place are usually the seat 
either of fatty degeneration, of calcareous deposit, or of chronic ar- 
teritis, with hyperplasia of the corpuscles belonging to the outer wall 
and to the perivascular sheath. The minute aneurisms which usually 
stud them vary, perhaps, from the size of a small pin's head down- 
wards, but occasionally they are as large as a grain of wheat, or larger. 
The escape of blood may, doubtless, in some instances come from a 
single ruptured aneurism or vessel; but much more frequently it takes 
place simultaneously from many lacerated vessels or aneurisms situated 
within some limited area. In some cases the haemorrhage is mainly 
from capillary vessels ; it is then apt to be spotty, and a careful exami- 
nation will probably reveal in the centre of each spot a capillary vessel, 
with its lymphatic sheath distended with blood — a capillary dissecting 
aneurism, in fact. In other cases, and more especially in those in 
which the effusion is considerable and in mass, the presence of miliary 
aneurisms can generally be easily recognized, and even the ruptured 
aneurisms discovered. But here also the rupture is first into the peri- 
vascular sheath, so that a dissecting aneurism precedes the final rup- 
ture by which the blood escapes into the surrounding nervous tissue. 
The quantity of blood which may escape into the brain -substance varies, 
roughly speaking, from a bulk the size of a pin's head up to one the 
size of a hen's egg or an orange. Groups of minute or capillary extrav- 
asations are occasionally alone present; and generally, when a large 



CEREBRAL AND SPINAL HEMORRHAGE. 



965 



hemorrhagic cavity exists, the tissues around are studded more or less 
abundantly with similar small hemorrhagic spots. The escaping 
blood tears up the brain-substance more or less irregularly; and thus, 
when its amount is large, a very irregular cavity is produced, the in- 
terior of which is occupied by blood mingled with the debris of the 
broken-down nervous tissue, while the margins are formed by the irreg- 
ular interdigitation of the lacerated brain-substance and of the periphe- 
ral portions of the clot. 

The extravasated blood speedily coagulates, and if the post-mortem 
examination be performed shortly after its effusion, will be found to 
present the ordinary characters of recent clot. If, however, the patient 
survive, changes gradually ensue in it and in the brain-substance 
around. The irregularities of the cavity get smoothed away, its form 
gets more rounded, and its margins denser and more defined. The clot 
contracts, becomes drier and more friable, assumes a brownish or rusty 
tint, and gradually undergoes more or less complete absorption : the 
final result being the formation either of a cicatrix (which can only 
happen if the effusion were very small) or, as far more commonly 
occurs, of a cyst traversed by delicate processes of connective tissue, 
and occupied by a thin serous or milky fluid, the parietes of which are 
studded more or less abundantly with pigmentary particles and crystals 
of heinatoidin. The time required for the total disappearance of a clot 
depends upon its size: a small one may be absorbed within a week or 
two, a very large one within six weeks. The effects of clots on the 
surrounding brain-tissue must not be omitted. In the first place, they 
always cause more or less displacement and pressure, and, if large, 
effect flattening of the convolutions, obliteration of the sulci, and dis- 
placement of subarachnoid fluid from a greater or less extent of the 
surface which overlies them. In the second place, the surrounding 
tissue, for some little distance, always becomes oedematous, yellow from 
imbibition of the coloring matter of the clot, and more or less softened. 
In the third place, the hemorrhagic effusion is very apt to provoke more 
or less inflammatory mischief in the parts which are in its immediate 
vicinity. And, lastly, coming on at a later period, atrophic changes 
are liable to appear, descending from the situation of the clot, along the 
under surface of the corresponding crus, through the pons into the 
anterior pyramid, and thence through the decussating fibres to the 
lateral column on the opposite side of the cord. 

Hemorrhage may occur into any part of the substance of the brain ; 
but it takes place mainly in the corpus striatum, and is then generally 
due to laceration of some of the twigs of one particular branch of the 
internal carotid, to which Charcot calls special attention, and which we 
have already referred to. After the corpus striatum, the parts most 
likely to suffer are the optic thalamus and the white substance of the 
brain immediately external to these bodies. Hemorrhage occasionally 
also takes place in the crus cerebri, in the pons, and in the cerebellum, 
and, though much more rarely, in the medulla oblongata. Large 
effusions may implicate the optic thalamus and corpus striatum at the 
same time, and even destroy these bodies completely. They are very 
apt, moreover, to rupture into the lateral ventricle, or, if they extend 



966 



DISEASES OF THE NERVOUS SYSTEM. 



outwards, into the subarachnoid tissue in the neighborhood of the 
island of Reil. In the latter case, more or less abundant effusion of 
blood takes place on to the surface of the brain ; in the former case, 
one or both lateral ventricles, or the whole system of ventricles, in- 
cluding the fourth, become inundated with blood and sometimes 
enormously distended. Hemorrhage into the pons is not unfrequently 
continued thence by rupture either into the fourth ventricle or into the 
subarachnoid tissue below. It is not common for more than one hemor- 
rhagic effusion of any extent to take place in the brain at one time. 
But it is by no means uncommon to discover, after death from cerebral 
hemorrhage, the remains of one or two or even more extravasations in 
addition to the recent one which has caused death. 

Hemorrhage into the ventricles is almost always secondary to hemor- 
rhage into the brain-substance or to rupture of aneurisms at the base. 

3. Cord. — Effusion of blood into the substance of the cord is very 
rare. It no doubt depends in some cases on the laceration of diseased 
vessels; but it is probably in the great majority of cases (as Charcot 
suggests) secondary to inflammatory softening. 

Symptoms and Progress. — 1. Brain. The term " apoplexy " is so 
commonly used to imply cerebral hemorrhage, and is on the whole so 
misleading when thus used, even if its scope be limited by the prefix 
" sanguineous/' that it may be well to observe here that typical apo- 
plexy — that condition in which the patient suddenly falls down in 
complete coma, with total abolition of motion and sensation, and of 
sense, with full pulse, and slow, stertorous breathing, is very rarely 
indeed observed in cases of effusion of blood within the cavity of the 
cranium. Further, in most works, and especially in those of the older 
school, much stress is laid upon the type of body which is most liable 
to apoplexy, on the habits of life which predispose to it, and on the 
various symptoms which were supposed for weeks, months, or even 
years, to herald the approach of the actual seizure. It is certain, how- 
ever, that although there was some amount of truth in the observa- 
tions which led to these generalizations — a sort of rough connection 
between the collective antecedents above hinted at and the superven- 
tion at some period or other of death, ushered in with an apoplectic 
seizure, or due to hemorrhagic effusion — there is little or no direct 
connection between them and the rupture of a bloodvessel in or on 
the brain. 

In a very large number of cases of effusion of blood the attack comes 
on suddenly and unexpectedly, although it may be freely admitted that 
in no inconsiderable proportion of them there has pre-existed, for a 
longer or shorter time, either chronic Bright's disease, or some distinct 
evidence that degenerative changes have been going on in the arterial 
system. In other cases there have been more or less distinct precursory 
symptoms, referable to some local disturbance of the cerebral circula- 
tion, caused either by partial obstruction of some artery or by the 
occurrence of capillary hemorrhage, or it may be by the actual forma- 
tion of some hemorrhagic cavity which, either from its smallness or 
from its situation, is unattended with striking symptoms or permanent 
injury. Among the symptoms here adverted to may be enumerated 



CEREBRAL AND SPINAL HEMORRHAGE. 



967 



headache, vertigo, confusion of thought, failure of memory, drowsiness, 
want of sleep, irritability of temper, and the like. Others are bleed- 
ing from the nose and retinal haemorrhage. But the most important 
are the occurrence of temporary paralysis, such as numbness or ting- 
ling on one side of the body or in the arm or leg, loss of power in the 
same parts, or in one-half of the tongue or face, or difficulty of articu- 
lation or of deglutition, and double vision. It must not, however, be 
assumed that any of these symptoms necessarily point to the occur- 
rence of haemorrhage. They may equally indicate the presence of a 
tumor or other localized lesion, or be connected with epilepsy or other 
purely functional affections of the brain. 

The symptoms which attend the actual effusion of blood into the 
brain are very various both in kind and in severity. Sometimes the 
patient, while engaged in his ordinary avocations, suddenly discovers 
that he has lost the use of his arm, and presently becomes hemiplegic; 
sometimes while engaged in conversation his articulation becomes thick, 
and he presently discovers that his mouth is drawn to one side, and 
that an arm and leg are limp and weak ; sometimes the first intimation 
that there is anything amiss is the accidental discovery by the patient 
that one side of his body is totally useless when he attempts to rise 
from his bed in the morning, or from a chair in which he has been 
sitting quietly or. dozing. In other cases the appearance of paralysis 
is attended or preceded by sudden giddiness or confusion of thought, 
or by a pain or sensation in the head which makes the patient cry out. 
In some instances he talks and acts for a few seconds like a drunken 
man. In some he suddenly becomes faint and collapsed, with pallid 
face, cold damp skin, feeble irregular pulse, and vomiting — the affec- 
tion is ushered in indeed with an attack of syncope, during which he 
may become more or less completely insensible, but from which he often 
recovers. In a few instances only does the patient become at once 
insensible, and then the attack is apt to commence with a convulsion. 
These last, it may be added, are for the most part cases in which blood 
is effused into the pons Varolii or on to the surface of the brain from 
rupture of a large vessel or aneurism. 

The further progress of the disease presents the widest range of va- 
riety. In some instances the patient's symptoms stop short at that in- 
distinctness of speech or that unilateral paresis with which he was prob- 
ably first seized ; and he remains in this condition for a few hours, or 
a few days, or a few weeks. In some instances these primary symp- 
toms become aggravated up to the supervention of absolute hemi- 
plegia, w T ith more or less anaesthesia or without it : in which condition 
again the patient may remain for a variable time, sometimes recovering 
completely sooner or later, sometimes undergoing imperfect recovery, 
and remaining more or less feeble on the affected side, or in some de- 
gree inarticulate through the remainder of his life. Not unfrequently 
headache or vertigo, or impairment of intellect, or alteration of temper, 
continues throughout the persistence of the paralysis, and continues 
even after its amelioration or disappearance ; occasionally there is tem- 
porary deviation of the eyes, and even of the head and neck, towards 
the paralyzed side. In many instances more or less profound coma 



968 



DISEASES OP THE NERVOUS SYSTEM. 



presently succeeds to the symptoms of invasion. This may come on in 
the course of a few minutes, or a few hours, or a few days, even in 
those cases in which the initial symptoms are of the mildest character. 
It generally supervenes before long in those whose first symptoms are 
symptoms of shock; the patient recovers from his faintness, perhaps to 
find himself hemiplegic, not improbably to feel fairly well : but by 
degrees drowsiness and stupor creep on and then gradually deepen into 
profound coma. 

But, however the coma may come on, whether it be gradual in its 
invasion, whether it supervene in the course of symptoms already 
pointing to cerebral haemorrhage, or whether it become developed in 
all its intensity within a few minutes or a quarter of an hour of the first 
signs of illness, its symptoms do not on that account present any dif- 
ferences. The patient lies on his back insensible, with the face more 
or less flushed, the skin moist, the pulse slow, perhaps irregular, but 
full and more or less hard, the respirations slow and attended with 
stertor or snoring as he draws his breath in, and puffing of the cheeks 
as he exhales, and more or less depression of temperature, which may 
continue for some hours. In the early condition of this, which is some- 
times termed the apoplectic state, the patient is still perhaps capable 
of being roused ; when spoken to loudly he may make some incoherent 
sound, when pinched or moved he may indicate by some movement or 
gesture that he is not altogether without feeling. But soon he becomes 
utterly unconscious. In this condition many various symptoms cluster, 
as it were around his unconsciousness. He may lie on his back quietly 
as if asleep, the muscles of his limbs presenting little deviation from 
the normal condition ; or the limbs generally, or on one side, may be 
flaccid and if lifted fall lifelessly back upon the bed; or there may be 
rigidity, in place of flaccidity, and more or less consequent resistance 
to the attempts to move them; or, again, convulsive twitches or more 
powerful spasmodic movements may occur from time to time either 
generally or on one side of the body. There may, in fact, be simply 
that failure of the muscles to move which stupor alone involves, or 
there may be general or unilateral paralysis with or without flaccidity, 
rigidity, or convulsive movements. In the face the same conditions 
may be observed ; sometimes the muscles remain in their ordinary con- 
dition of repose; sometimes more or less obvious facial palsy is ob- 
served upon one side, sometimes twitching of the muscles. The eye- 
lids are generally closed. The condition of the eyes varies : frequently 
the pupils are dilated, especially towards the fatal close ; sometimes, 
and more especially in cases of haemorrhage into the pons, they are 
contracted ; often they are natural ; they are sometimes irregular and 
sometimes quite insensible to light ; both of these latter are symp- 
toms of considerable significance. In the early state the patient, 
though unable to masticate, is still able to swallow fluid or food placed 
in the back of his mouth; when, however, the case is going on un- 
favorably, the power of deglutition fails absolutely. Respiration is, as 
has been stated, usually slow, but it is often also irregular, and is liable 
to cease completely for some seconds. Sometimes the patient breathes 
as quietly as a child. When, however, a fatal termination is impend- 



CEREBRAL AND SPINAL HEMORRHAGE. 



969 



ing, stertor (even if it were not before present) comes on ; and mucus 
and other fluids accumulate at the back of the throat and in the air- 
passages, the respiratory sounds become attended with loud rattling 
! sounds, and the movements often accelerated. The character of the 
pulse varies: at first probably it is slow, full, and hard, but it may be 
of natural frequency, and present no deviation whatever from the nor- 
j mal : with the continuance of coma, however, it is apt to increase in 
1 frequency, and may rise to 120, 140, or 160 in the minute. The 
face is usually flushed, the skin more or less moist ; and towards the 
• end of life profuse perspirations usually if not always break out. It 
need scarcely be added that the patient has retention of urine, and loss 
of control over his alvine evacuations. Inability to swallow, the ac- 
cumulation of fluids in the fauces and air-passages, indifference of the 
pupils to light, failure of the eyelids to close when touched, extreme 
rapidity of pulse, and the occurrence of profuse perspirations are phe- 
nomena of the gravest omen. 

In some cases the stupor of coma passes in the course of a few min- 
utes, or of a few hours, or of a few days, into that of death. But in 
a considerable number of cases the patient, after a longer or shorter 
time, slowly emerges from it, regains his consciousness more or less 
completely, and probably is found to be paralyzed on one side, and to 
present a greater or less number of other indications of cerebral mis- 
chief. From this point sometimes the recovery is rapid and thorough; 
j sometimes more or less complete hemiplegia continues temporarily, or, 
after more or less improvement, for life ; sometimes he has hemianes- 
thesia as well as paralysis; sometimes his speech remains indistinct; 
sometimes he has more or less complete aphasia; sometimes he com- 
plains of headache or giddiness; sometimes he has loss of memory or 
failure of intelligence, or emotional perversion ; or he may be stupid or 
demented, and then hot unfrequently he fails to control his bowels or 
his bladder. It is obvious that the various conditions here described 
are in the main identical with those which are apt to follow on hemi- 
plegia coming on without insensibility ; and that, in fact, but for the 
circumstance that the supervention of coma on the whole implies either 
a large effusion of blood, or its effusion into some vital part, and that 
coma itself brings with it special dangers, there is no essential differ- 
ence in the subsequent progress of those cases of cerebral haemorrhage 
which are attended with coma and those which are free from coma. 

It has already been pointed out that haemorrhage may occur into 
different parts of the brain ; it may be added that the symptoms will 
be determined partly by this circumstance, partly by the size of the 
| clot, and partly by the rapidity with which the blood is effused. When 
i it occurs in the corpus striatum or in the white matter or convolutions 
of the brain in relation with the motor tract, or in the crus cerebri (and 
| it is usually in the corpus striatum or some other part of the motor tract 
J that it does occur), motor hemiplegia will almost necessarily follow, 
and will probably be more complete according as the amount of brain- 
substance destroyed or compressed is larger. If, however, the effusion 
take place into the white matter of the hemisphere, paralysis is more 
likely to be absent than if it occur lower down ; if it take place in the 



970 



DISEASES OF THE NERVOUS SYSTEM. 



crus, it is more probable that the third or fourth or some other of the 
nerves on the same side as the clot will be implicated than if it occupy 
the corpus striatum. Henii anaesthesia by itself is rarely, if ever, 
present ; it is not, however, unfrequently associated with hemiplegia, 
under which circumstances probably the haemorrhage either is in the 
optic thalamus, or involves that body or the parts external to it, or is 
in the crus. If blood primarily effused into the corpus striatum or 
other parts immediately bounding the lateral ventricle escape with 
sudden violence into the ventricular cavities and floods them, the pres- 
sure which is at once exerted on a large number of ganglia essential 
to life induces sudden profound coma with general paralysis and flac- 
cid ity of the limbs. If, also, the surface of the brain be suddenly del- 
uged with blood, profound coma almost immediately ensues, which is 
often attended with convulsions, by no means necessarily with paraly- 
sis, and in some cases, especially if it be at the base, by (as Dr. Jack- 
son suggests) inequality of pupils. When haemorrhage occurs into the 
pons, there are often convulsions, and usually sudden and profound 
coma, and general paralysis, attended at the commencement with con- 
traction of pupils, and the case is rapidly fatal. Sometimes, however, 
the effusion here is small in amount and unsymmetrical in position, in 
which case the paralytic symptoms will probably be more or less irregu- 
larly distributed; there will perhaps be hemiplegia, with more or less 
complete implication of various sensory and motor nerves situated 
either on the side opposite to the hemiplegia, or irregularly on both 
sides ; there is apt also to be more or less serious interference with the 
muscles of speech and deglutition — the usual symptoms, in fact, of bul- 
bar paralysis. Haemorrhage into the cerebellum is often attended with 
severe occipital pain, vomiting, and especially with vertigo. Paraly- 
sis is often entirely absent, but the patient, if able to walk, is pecu- 
liarly liable to stagger. 

We have already pointed out that a patient who has had blood effused 
into his brain, whether he has had coma from which he has emerged, 
or whether he has had a simple attack of paralysis, and has attained | 
that stage at which all present fear of coma has passed away, may 
rapidly recover from all his symptoms, may recover slowly, may 
recover imperfectly, or may remain without any improvement what- 
ever. We have not, however, referred to the important fact that vari- 
ous complications may arise in the progress of the case. The principal 
of these may be briefly considered. 1. The presence of a clot, and of 
the collateral oedema which always attends its presence, is very apt to 
induce at any time during the first few weeks after its formation some 
inflammation in the surrounding brain-tissue — an occurrence which is 
often indicated by more or less elevation of temperature, rapidity of 
pulse, return of paralysis, drowsiness, and impairment or loss of con- 
trol over the emunctories, and may lead to coma and death. 2. Bed- 
sores are apt to form. In some instances these come on when the 
patient is bedridden, or has, continued for some length of time in a 
fatuous or semi-comatose condition, just as they may come on in any 
other persons who are confined to their beds, and uncleanly in their 
habits. But they are also apt to appear, and then mainly upon the j 



CEREBRAL AND SPINAL HAEMORRHAGE. 



971 



buttock of the paralyzed side, from the second to the fourth day of the 
attack, apparently in consequence of some direct influence transmitted 
from the seat of lesion in the brain. The formation of these early bed- 
sores is always a bad sign, and almost without exception foretells an 
early fatal issue. 3. Inflammation of internal organs, such as pneumonia, 
dysentery, ulceration, and the like, occasionally supervenes. 4. Not 
! unfrequently, after the second or third week, or later, if the paralyzed 
1 limbs remain paralyzed, rigidity and contraction gradually ensue, asso- 
| ciated after awhile, in some cases, with wasting of the muscles. This 
rigidity is not to be confounded with the temporary rigidity that is 
I sometimes observed at the commencement of paralysis, and is due ap- 
parently to irritation, but is the consequence of secondary degenerative 
| changes in the course of the lateral columns of the spinal cord, and is 
j permanent. It is observed by Trousseau that in those rare cases of 
; hemiplegia in which the arm recovers more rapidly than the leg, the 
prospects of the patient are very gloomy, that the leg becomes stiff 
| and painful, that imbecility comes on, and the patient usually dies 
within the year. Whatever the explanation of the imbecility in these 
cases may be, it seems pretty certain that the arrested recovery of the 
leg is sometimes due to the fact that degenerative disease has already 
commenced within the cord. 5. All patients who have had one attack 
of cerebral haemorrhage are specially likely to have subsequent attacks, 
and sometimes two or three of these occur, adding complexity to the 
I patient's symptoms, at irregular intervals, previous to the fatal issue 
of the case. In the last place, it may be observed that, partly from 
the effect of the primary lesion, partly from the associated diseased 
state of arteries, partly from pressure, oedema, inflammation, or degen- 
eration of surrounding parts, many additional symptoms are liable to 
come on — among others, epileptiform attacks, delirium, mania, or 
dementia. 

2. Cord. — Haemorrhage into the arachnoid cavity or subarachnoid 
tissue, or into the substance of the cord is so rare, except as a conse- 
quence of injury or of pre-existing disease which has already caused 
serious symptoms referable to the cord, that it is scarcely necessary to 
discuss the symptomatology of these lesions. It is sufficient to say 
that haemorrhage around the cord will naturally cause the symptoms of 
pressure, namely, more or less loss of the power of motion, associated 
with little or no impairment of sensation ; and that the effects will vary 
according to the seat of the effusion, its extent, and the degree of pres- 
sure exerted by it ; and that haemorrhage into the substance of the cord 
| will be attended with precisely those symptoms which occur in inflam- 
j matory softening involving the whole thickness of the cord. 

Treatment. — When a patient is seized with sudden paralytic symp- 
toms due, as we suppose, to haemorrhage, there is little to be done save 
to keep him perfectly quiet, mentally and bodily, to make him lie 
down with his head somewhat elevated, in a room of equable but not 
elevated temperature, and to feed him sparingly with milk and fari- 
naceous food. There is no harm, probably, even if there is no good, 
in giving him cooling drinks, and in administering medicines which 
are supposed to check haemorrhage. A powerful purgative is often 



972 



DISEASES OF THE NERVOUS SYSTEM. 



given, but it is questionable whether the straining which attends its 
action is not more injurious to the patient than the retention of fecal 
matter in the bowels. If coma have come on again, there is little to 
be clone beyond leaving the patient at rest. Some bleed, but bleeding 
will not benefit those who have large effusions of blood in the pons or 
ventricles, or on the surface ; and those who have large haemorrhages 
elsewhere for the roost part recover from their coma without any such 
assistance. Further, bleeding is probably quite incompetent to arrest 
cerebral haemorrhage. Nevertheless, we are inclined to believe that 
the guarded removal of blood in these cases may sometimes prove bene- 
ficial by diminishing the pressure of blood within the skull, or, as Sir 
Thomas Watson suggests, by relieving the congestion of the right side 
of the heart, which is often manifested by engorgement of the veins of 
the head and neck, and livid ity of surface. At all events a single 
bleeding will probably have no injurious effect whatever. It is cus- 
tomary to give powerful purgatives in these cases, such as a couple of 
drops of croton oil alone, or mixed with a little castor oil ; and on the 
whole the practice appears to be good ; purgation tends to derive (as the 
expression is) from the head ; and in cases of profound coma does not 
induce that powerful straining which is so great an objection to its em- 
ployment when the patient is sensible. Other measures which may be 
adopted are the application of cold in the form of evaporating lotions, 
or of ice to the shaven head : or of counter-irritants, such as mustard 
plasters, to the head, back of the neck, and legs. During the further 
progress of paralysis following on haemorrhage, the chief things to 
do are still to keep the patient quiet, and free from either mental or 
bodily excitement, to regulate his hours and employments, to keep his 
bowels regular, if necessary, by the use of opening medicines, to relieve 
all discomforts and secondary affections under which he may happen 
to labor, to counteract, as far as possible, the effects of any renal or 
other organic disease of which he is the subject, and to attend very 
carefully to his diet. As a rule, all alcoholic beverages should be in- 
terdicted, or if circumstances render their use necessary, should be 
allowed only in small quantities, and in a dilute form. The patient 
should be well nourished, but the amount of food given him should 
not exceed what is essential for his well-being. The food, moreover, 
should be wholesome and readily digestible. It is often recommended 
that the patient should be restricted to a vegetable diet and milk — a 
diet which is doubtless very appropriate if there be any chronic renal 
affection. But if his abdominal viscera be healthy, we do not see how 
such diet should have any superiority over a diet containing a fair 
proportion of animal food. As regards the affected limbs, friction 
and galvanism are sometimes efficacious, when the acute symptoms 
have passed away, in promoting the restoration of the impaired motor 
powers. 



OBSTRUCTION OF CEREBRAL ARTERIES. 



973 



OBSTKUCTION OF CEREBRAL ARTERIES. 

(Thrombosis. Embolism. Softening.) 

Causation and Morbid Anatomy. — We have drawn attention to the 
i fact that the group of arteries supplying the brain, although anasto- 
mosing freely at the circle of Willis, have no further communication 
with one another excepting by means of the capillary vessels situated 
I at the periphery of their several areas of distribution ; that the same 
, arrangement holds good with respect to every branch of these arteries, 
down to their smallest twigs; and that hence any obstruction, however 
produced, in any of the primary branches, or in any one of their more 
remote branches, however small they may be, puts a stop to the circu- 
lation of blood in the district to which the obstructed vessel leads, and 
involves its degeneration and death The same rule obviously does not 
apply with equal force when obstruction takes place in the basilar or 
in either of the internal carotid arteries below the anastomosis, since by 
means of that anastomosis blood for the most part finds its way readily 
from the pervious trunks to the branches of the obstructed vessel, 
j Nevertheless, such obstruction, and even obstruction of the common or 
internal carotid in the neck, occasionally influences seriously the nu- 
trition of that portion of the brain with which the obstructed vessel is 
in relation. The arteries of the cord, on the other hand, are small, 
derived or reinforced from many sources, and rarely, so far as we know, 
become obstructed, or if obstructed, instrumental in the production of 
degenerative changes in the substance of the cord. 

The causes of obstruction of the cerebral arteries are various. In 
many cases the arteries at the base of the brain in persons advanced in 
life become rigid, thick-walled, and the seat of atheromatous or calca- 
reous degeneration; and as a consequence of the advance of these pro- 
cesses it sometimes happens that one of the diseased vessels becomes 
reduced in calibre, or is rendered altogether impervious. In a consid- 
erable number of cases, again, one of the arteries at the base of the 
brain or one of its primary branches becomes obstructed in a greater or 
lesser portion of its length by a clot or thrombus, which fills it, ad- 
heres to its surface, and after awhile undergoes degenerative changes, 
in which also the vascular parietes probably share. The causes of such 
| thrombosis are not always obvious. Occasionally it is due to the fact 
i that the affected vessel leads to some diseased tract in Avhich the smaller 
j vessels have become involved and obstructed ; and the coagulation of 
I blood in it is therefore secondary. Sometimes, possibly, it is due to 
the special tendency which the blood appears to have in some dyscrasic 
conditions to undergo spontaneous coagulation. Sometimes it is deter- 
mined by disease of the arterial walls, such as roughening from 
atheromatous or other chronic processes, or inflammatory thickening. 
Whether under such circumstances the thickening is specific or not it 
is difficult to say, but it is certain that it not unfrequently occurs in the 
course of secondary or tertiary syphilis. But perhaps the most interest- 
ing cause of obstruction is the detachment of granulations from diseased 



974 



DISEASES OF THE NERVOUS SYSTEM. 



valves on the left side of the heart, their conveyance to the arteries of 
the brain, and their impaction, usually at the point of bifurcation of an 
artery, or at some other spot where the vessel is too small to allow of 
their further transmission. The embolus usually soon becomes the 
nucleus for the development of a thrombus extending to a greater or 
less distance in either direction along the channel of the obstructed 
artery. 

Obstruction of the arteries at the base from atheromatous or earthy 
degeneration is observed (as might be supposed) mainly in persons ad- 
vanced in life, and especially in those suffering from arterial disease 
elsewhere, or who are the subjects of chronic renal disease, or have led 
laborious or debauched lives. The obstruction in these cases usually 
occurs in one of the arteries forming the circle of Willis, or in one of 
the trunk-vessels below this anastomosis. 

Obstruction from thrombosis is not uncommon in the vertebrals, the 
basilar, the internal carotids, and their several primary branches ; and 
indeed not very unfrequently involves two or three of these vessels one 
after the other at irregular intervals. Obstruction from thrombosis 
connected with arterial degeneration is an affection of advanced life; 
as a consequence of syphilis, it is mainly a phenomenon of early adult 
life and of middle age. 

Obstruction referable to embolism is in the great majority of cases 
the consequence of rheumatic inflammation of the valves of the heart ; 
it may, however, follow on degenerative lesions of these same parts and 
the detachment of masses of calcareous or atheromatous matter, or of 
fibrinous tubercles which have become developed on the degenerate 
surfaces. It is obvious, therefore, that embolism may occur at almost 
any period of life, yet it is certainly most common from the time of 
puberty up to the age of forty or fifty. Obstruction from embolism 
almost invariably affects the middle cerebral artery in some part of its 
course, and in the large majority of cases the middle cerebral of the 
left side. 

The changes in the brain-substance which follow upon obstruction 
of one of the cerebral arteries are (excepting when the obstruction takes 
place below or in the circle of Willis) almost accurately limited to the 
district which the obstructed vessel supplies. The affected region be- 
comes softened, opaque white, yellowish, or greenish, and often mottled 
with light red patches, or even minute extravasations of blood ; it often 
becomes so soft that it breaks down readily into a pulp under the 
finger, or admits of being washed away under the impulse of a stream 
of water. The microscopic characters which it presents depend on the 
appearance of granule-cells in greater or less abundance, on the degen- 
eration of the nervous elements, more especially of the white substance 
of Schwann, and its conversion into masses of refractive globules, and 
on the accumulation in the walls of the vessels and perivascular sheaths 
of more or less numerous fatty granules. Patches of softening from 
obstruction, especially if of small size, may, like apoplectic clots, un- 
dergo absorption, and leave behind them a mere scar or a cavity con- 
taining serous or milky fluid. If of large size, they may undergo more 
or less diminution of bulk, and involve obvious shrinking of the mass 



OBSTRUCTION OF CEREBRAL ARTERIES. 



975 



of brain in which they are contained. Not unfrequently inflammatory 
changes go on in the brain-substance around them. 

Symptoms and Progress. — The symptoms due to the obstruction of 
one of the cerebral arteries so closely resemble those caused by haernor- 
rhage that, if there be no appeal to other facts than those afforded by 
the cerebral symptoms which are present, it is utterly impossible in the 
great majority of cases to distinguish the one affection from the other. 
It is stated by Recamier and by Todd, and their views are supported 
by Trousseau and many others, that whenever hemiplegia, complete 
and absolute, occurs suddenly without loss of consciousness, it is clue to 
softening and not to haemorrhage. And, in reference to this point, it 
may be well to point out that it is rational to suppose that the mere 
sudden loss of function in a limited portion of brain-tissue (as occurs in 
softening) should be attended with less general disturbance of the 
cerebral functions than the extravasation of blood into a similarly 
limited space, which not only destroys the tissues which it infiltrates, 
but, from its bulk, causes more or less serious pressure on surrounding 
parts. The rule indeed may doubtless, within certain limits, be ac- 
cepted as the expression of a fact; but it is a rule, nevertheless, to 
which there are many exceptions, for in many cases of softening from 
arterial obstruction, the hemiplegia, if sudden, is not complete, and in 
some the attack is ushered in by loss of consciousness; while, on the 
other hand, the occurrence of haemorrhage, as we know, is in a large 
number of cases unattended with insensibility. 

Various prodromal symptoms of cerebral softening are often enumer- 
ated ; but it is clear that in most of the varieties of softening now 
under consideration no symptoms of the kind are likely to be met with. 
They can attend neither embolism nor thrombosis. And any that may 
be referred to disease of the arterial walls are equally indicative of fu- 
ture haemorrhagic effusion. As a matter of fact, the symptoms due to 
arterial obstruction are always sudden in their onset, and for the most 
part occur unexpectedly at a time perhaps when the patient seems to 
be in perfect health. The seizure comes on in various ways : some- 
times the patient, who is walking or making some exertion, or perhaps 
even sitting down quietly, is attacked with sudden vertigo, and more 
or less confusion of thought, and tumbles or throws himself forward on 
the ground ; sometimes he is seized with sudden pain in the head of 
such severity that he cries out ; sometimes he becomes suddenly faint, 
and occasionally this faintness is attended with a slight convulsion. 
[In some of the recorded cases the patients have manifested at the mo- 
ment of seizure great emotional disturbance, laughing or crying immod- 
erately, so that the attack may occasionally simulate one of hysteria.] 
But, however various these initial symptoms, it is almost always dis- 
covered so soon as the momentary attack is passed that more or less 
complete hemiplegia is present. Now, it is almost needless to say that 
the character of the symptoms which present themselves and their 
severity must depend largely upon the size of the vessel obstructed and 
the part to which it is distributed ; in other words (as also in haemor- 
rhage), upon the amount of brain-substance which becomes incapaci- 
tated, and on its situation. 'Thus we know that affections of the pos- 



976 



DISEASES OF THE NERVOUS SYSTEM. 



terior cerebral lobes and of the cerebellum are always more obscure 
in their symptoms than those which involve the anterior portions of the 
brain, and more especially than those which involve its base. An$ 
hence we can readily understand that obstructions arising in the course 
of the posterior cerebral and cerebellar arteries lead to less definite, if 
not less serious, consequences than obstructions in the course of the 
anterior or middle cerebrals. It is very important, however, for the 
purposes of diagnosis to refer to the exact distribution of the various 
intracranial vessels which has been given on a former page ; and espe- 
cially is it important to bear in mind that it is from the basilar artery 
that the pons mainly receives its vascular supply ; that the posterior 
cerebral artery is distributed not only to the posterior part of the cere- 
brum but especially to the posterior part of the optic thalamus, to the 
corpora geniculata and corpora quadrigemina; and that in the great 
majority of cases, and certainly in almost all cases of embolism, the ob- 
struction occurs in the middle cerebral artery or in some one of its 
branches ; and that the district which consequently then undergoes soft- 
ening is that to which this vessel is distributed, or certain parts of that 
district, which includes the greater part of the corpus striatum, the inter- 
nal capsule, the anterior half of the optic thalamus, and nearly the whole 
of the antero-lateral region of the brain, inclusive of the island of Reil 
and the convolutions which surround the fissure of Sylvius. It is hence 
obvious that in the case of embolism the main symptom which the 
patient would be expected to present is more or less complete (generally 
complete) hemiplega, not improbably associated with some degree of 
anaesthesia and more or less profound impairment of intelligence ; and 
that if the disease occupy the left side of the brain (as it usually does 
in embolism), either marked aphasia will be present, or total inability 
to utter articulate sounds, or both of these conditions in combination. 
Other symptoms are generally associated with those which have been 
specified — symptoms, however, which are not special to softening; 
these are vertigo, headache, sickness, rigidity of the affected limbs, loss 
of control over the bladder and rectum, and the like. 

The subsequent progress of cases of obstructed cerebral arteries de- 
pends largely upon the extent of softening and its situation. If the 
patch be small (even if it be in the distribution of the middle cerebral) 
recovery as complete as occurs after some cases of effusion of blood may 
be expected. [The same rule in regard to the order in which the dif- 
ferent parts of the body regain the power of motion does not seem to 
obtain in the hemiplegia depending upon embolism of a cerebral artery 
as in that following upon apoplexy, for it is not uncommon in the former 
case for evidences of returning strength to appear in the arm, while the 
leg continues motionless.] In most cases, however, recovery does not 
take place; in some the patient improves up to a certain point; in 
some he remains, so far as his mental and motor failures are concerned, 
much as he was immediately after his seizure. Occasionally, and espe- 
cially if the case be one of thrombosis and not of embolism, several of 
the cerebral arteries, and even the main trunks of these vessels, may be 
obliterated at successive intervals, each attack adding its own special 
symptoms to those which had resulted from previous lesions. It re- 



OBSTRUCTION OF CEREBRAL ARTERIES. 



977 



mains a fact, however, that the patient rarely recovers completely from 
the effects of thrombotic or embolic softening; that if he has become 
aphasic, the aphasia continues in a greater or less degree; that hemi- 
plegia for the most part persists, and becomes followed ere long by that 
form of contraction which results from secondary lesion of one of the 
lateral columns of the cord ; and that occasionally arthritic effusion or 
I inflammation ensues, or wasting of some of the muscles. Further, the 
I intellect, already probably impaired, is apt to fail, and the patient after 
awhile to become bedridden and childish. It must be added that bed- 
! sores occasionally form rapidly after softening, as they do after hsemor- 
i rhage; and that inflammatory processes may come on around the soft- 
ened patch and bring with them special symptoms. It follows that on 
the whole the prognosis in cases of softening is very unsatisfactory, and 
that even if patients survive they are apt to survive in a more or less 
maimed or wrecked condition. Death may occur at any period. Some- 
times it comes on early, the patient dying from coma, or the formation 
; of bedsores, or failure of nutrition, or from pneumonia, or some other 
such complication. Death at a later period may be consequent on the 
recurrence of apoplectic attacks or on the supervention of inflammation 
around the focus of disease ; or it may be clue to asthenia or some inter- 
j current disorder. 

It will be gathered that there is for the most part extreme difficulty 
in determining of any case which comes before us whether it be one of 
sanguineous effusion or one of softening in consequence of arterial ob- 
struction. In many cases, indeed, there is nothing whatever to aid us 
in coming to a differential diagnosis. The chief points on which re- 
liance must be placed are : first, our knowledge of the relative seats of 
haemorrhage and of softening and of the different symptoms which 
they are hence likely to evoke; second, the clinical history of the 
patient and the state of his various organs — thus the case is likely to 
be one of embolism if there be heart disease present, or if there be a 
history of his having had some former cardiac mischief, or even if he 
have had an attack of acute rheumatism; it is not unlikely to be one 
of thrombosis if the patient have had a chancre, or if he be suffering 
from or present traces of having suffered from the secondary or later 
symptoms of syphilis; it is almost certain to be hemorrhagic if we 
discover the presence of albuminuria or chronic renal disease, or arterial 
degeneration, or haemorrhage into the retina?; and, third, the age of the 
patient — cerebral haemorrhage being on the whole a disease of advanced 
life, embolism occurring indifferently at all ages from puberty upwards. 
We need scarcely repeat that the occurrence of sudden and complete 
hemiplegia without loss of consciousness and without any premonitory 
symptoms, points strongly to arterial plugging, while the more gradual 
development of symptoms, culminating in hemiplegia and coma, is 
much more characteristic of cerebral haemorrhage. 

Treatment. — It is needless to lay down any specific rules of treat- 
ment. We cannot reopen an obstructed artery ; we cannot hope that 
the area to which it leads will be fed by collateral channels. The 
softened part remains necrosed, and the best thing that can happen is 
that it shall shrink into an inert mass or undergo absorption. It may, 

62 



978 



DISEASES OF THE NERVOUS SYSTEM. 



however, during this process induce inflammatory mischief in the parts 
around. This contingency should be guarded against as much as pos- 
sible. For this and various other reasons, the patient should be kept 
quiet and cleanly, his bowels should not be allowed to become consti- 
pated, and his food should be nutritious, but easy of digestion, and not 
too abundant. But, indeed, the same general treatment is applicable 
to these cases as is applicable to cases of paralysis after haemorrhage, 
and need not therefore be more particularly considered. 



HYDROCEPHALUS AND HYDRORHACHIS. 

[Cerebral and Spinal Dropsy.) 

Causation and Morbid Anatomy. — 1. Dropsical accumulations in the 
cavities connected with the brain and cord are not uncommon, their 
chief seats being the subarachnoid space and the ventricles. A relative 
excess of subarachnoid fluid, which has been mistaken for dropsy, is 
usually observed in connection with the shrunken brains of old persons 
and of many of those who die demented or fatuous, or the victims of 
some other chronic forms of insanity. Whenever any portion of the 
brain, whether from congenital defect or as a consequence of disease, 
wastes, the space which it formerly filled becomes occupied either by 
an excess of subarachnoid fluid or by fluid accumulated in a local dila- 
tation of one of the ventricles. Further, more or less effusion of serum 
attends the progress of many morbid conditions: such especially as 
inflammation, morbid growth, and softening. Thus, in some cases of 
meningeal inflammation, inflammatory products with excess of fluid 
accumulate in the subarachnoid space ; in some cases the substance of 
the brain becomes generally wetter or more succulent than natural, or 
serous infiltration (collateral cedema) occurs in the vicinity of foci of | 
disease ; while in some cases again (and these are the most frequent 
and the most important) the lateral ventricles, the third ventricle, or 
the fourth ventricle, or all of them together, become largely distended 
with fluid. In all these latter cases the excess of fluid in one situation 
is balanced by its removal from other situations ; and hence, as a rule, 
excess of fluid on the surface is attended with comparative absence of 
fluid from the ventricles ; and excess of fluid in the ventricles or in the 
substance of the brain causes flattening of the convolutions, oblitera- 
tion of the sulci and dryness of the subarachnoid tissue. The effusion 
of fluid in either of these situations plays a more or less important 
part in the production of symptoms in the cases which it complicates; 
but by far the most important of these varieties of dropsy, in this re- 
spect, is the intraventricular, which is so commonly associated with 
the presence of tubercles or other tumors of the brain, or of meningeal 
inflammation, and which occasionally arises (both in children and in 
adults) as an independent malady. When limited to the ventricles, 
it is often referred either to compression or obstruction of the venae 
Galeni, or to closure of the communication with the subarachnoid tissue 
which exists at the posterior extremity of the fourth ventricle. 



HYDROCEPHALUS AND HYDKORH ACHIS. 



979 



The most important arid most striking forms of dropsy are those 
which are congenital or come on without obvious cause shortly after 
birth. Of these, some are associated with malformation, others are 
independent of malformation. 

2. Among the former of these classes must be included, in connec- 
tion with the brain, hydromeningocele and hydrencephalocele : in 

! connection with the cord, spina bifida. In hydromeningocele and hy- 
■ drencephaloeele, a congenital perforation is present, either, as is most 
common, in the occipital bone, or in some other part of the vault of 
the cranium, through which protrudes, in the form of a tumor, either 
the membranes of the brain alone, with a circumscribed accumulation 
of serum (hydromeningocele), or a portion of the brain nipped off, as 
; it were, from the rest, usually containing within it a dilated dropsical 
| diverticulum from one of the ventricles (hydrencephalocele). Spina 
bifida generally occurs in the sacral or lumbosacral region, but may 
be met with in the neck or any other part of the spine. It forms a 
i rounded tumor, usually with a central dimple, and is due partly to 
the fact that the arches of the vertebrse in the situation of the tumor 
have remained ununited, and partly to the fact that the membranes of 
the cord are there expanded and distended with dropsical fluid, and 
protrude through the abnormal fissure. In some instances the mem- 
branes alone protrude, and we have then a condition which is equiva- 
lent to hydromeningocele. But much more commonly (especially if 
I the disease be at the lower end of the spinal canal), the cauda equina 
is prolonged into the cavity. The filum terminale is then attached 'to 
the centre of the concavity of the cyst, causing the dimple to which 
reference has been made ; and the nerves of the cauda equina accom- 
panying this to the posterior aspect then arch forwards across the cavity, 
double upon themselves, to reach their several foramina. If (as some- 
times happens in such cases as these) the central canal of the impli- 
cated portion of the spinal marrow is dilated into a cyst, we have a 
condition which is the exact counterpart of hydrencephalocele. 

3. Congenital or early developed dropsy (independent of malforma- 
tion) probably always occupies the ventricular cavities ; although in 
some cases, and then apparently by accident, fluid becomes effused also 
into the cavity of the arachnoid. Chronic hydrocephalus (as it is gen- 
erally called) sometimes commences during the later period of intra- 
uterine life, and the child is born already hydrocephalic. More fre- 
quently, however, the first manifestation of the disease occurs between 
the time of birth and six months after that event. It may, however, 

1 come on at any time previous to the union of the cranial sutures ; and 
! a few cases are recorded in which the supervention of dropsy shortly 
; after this union has caused the bones again to separate. The fluid 
j which accumulates in hydrocephalus is of higher specific gravity than 
i cerebro-spinal fluid, and contains albumen, chloride of sodium, and 
| urea. It mostly occupies the lateral, third, and fourth ventricles ; and 
| its gradual accumulation in them leads to their dilatation, to the flat- 
tening of the various projecting ganglia, to the rounding of the several 
! cavities, and to the enlargement of their orifices of communication. In 
this way the lateral ventricles may become enormously dilated, the 



980 



DISEASES OF THE NERVOUS SYSTEM. 



lateral walls of the third ventricle may be opened outwards, until they 
become horizontal, and lost, as it were, in the common floor of the 
general ventricular cavity, and the foramen of Monro and the fissure 
passing back from thence beneath the fornix may be so much dilated 
as to form a free archlike communication (of which the expanded 
third ventricle forms the floor) between the two lateral ventricles. The 
dilatation is not, however, always uniform or general; in some cases 
one lateral ventricle is much more enlarged than its fellow, or one por- 
tion of a ventricle much more expanded than another part of it. In 
some cases, indeed, the posterior cornu becomes isolated from the rest 
of the cavity, and forms an independent cyst. In other cases again, 
the third or the fourth ventricle may remain unaffected. On the other 
hand, it may happen that the dropsy mainly or wholly involves the 
third or the fourth ventricle, which is then cut off by adhesion from 
the other cavities. 

The effect of the gradual distension of the lateral ventricles upon 
the cerebrum is remarkable. We have pointed out that the various 
elevations and depressions in the ventricular walls become effaced, and 
that the lateral ventricles tend to communicate freely with one another 
in consequence of the displacement upwards of the corpus callosum, 
together with the septum lucidum and fornix. We must add that the 
convolutions on the surface of the organ tend, pari jicissu, to become 
unfolded, and that finally, in extreme cases, the gray matter of the 
convolutions forms a continuous smooth plain over the surface of the 
dilated hemispheres, which at the same time become reduced in thick- 
ness to a half or a quarter of an inch, or, in some situations, to that of 
writing-paper. Under these circumstances the dilated ventricles not 
unfrequently contain several pints of fluid ; and, indeed, cases are quoted 
by Trousseau in which 30, and even 50 pounds of dropsical fluid were 
found in them. Occasionally it happens, as in the well-known case of 
the man Cardinal, reported by Dr. Bright, that in the course of the 
disease some rupture of the surface of the brain or of its meninges 
occurs, and that consequently the fluid originally contained in the ven- 
tricles becomes accumulated in the cavity of the arachnoid, while the 
brain lies collapsed and flaccid on the base of the skull. 

The effects of hydrocephalus on the skull, on the nervous functions, 
and on the development of the child, are very important. As the fluid 
within it accumulates, the head gradually enlarges at the expense of its 
lateral and upper part ; the two halves of the frontal bone, the parietal 
bones and the occipital bone open (as Trousseau • expresses it) like the 
petals of a flower, and are thrown outwards, while the intervals be- 
tween them become proportionately widened. The forehead, the sides 
of the skull, and the occipital region, therefore, all protrude, while the 
head becomes somewhat flattened at the top ; and, at the same time, 
some want of symmetry is usually apparent. The inordinate size and 
strange shape of the skull impart to the comparatively small face below 
it a peculiar aspect, which is aggravated partly by the emaciation which 
is usually present, and partly by the influence of the enlarging skull 
on the orbits and eyelids. The upper walls of these cavities are dis- 
placed downwards by the pressure to which they are subjected from 



HYDROCEPHALUS AND HYDRORHACHIS. 



981 



1 above, while the upper eyelids, with the eyebrows, are drawn upwards 
j over the forehead by the tension of the stretched pericranial integu- 
j ments. The eyes consequently become somewhat prominent, and at 
the same time present a peculiar staring character, from the fact that 
the sclerotic coat is habitually visible above the upper margin of the 
cornea. The child almost always emaciates, notwithstanding that its 
j appetite may continue good, the frame remains undeveloped, and the 
i limbs become puny and shrunken. 

To revert to the consideration of the changes which take place in 
! the skull, and the peculiarities which it presents. The integuments 
I become attenuated and tense, the superficial veins remarkably distinct, 
j and the hair scanty and poor. The displaced bones also become thin, 
; and the serrations of their edges, by means of which the sutures should 
be closed, irregular and straggling. Further, as the case progresses, 
nuclei of ossification appear irregularly in the tense membrane which 
intervenes between the separated bones, and these grow into irregular 
osseous plates, termed ossa triquetra. After a time, with the aid of 
these intercalated bones, the sutures and fontanel les may become en- 
tirely closed. This closure, however, may not take place for twenty 
years or more. 

Internal hydrorhachis, or dropsy of the central canal of the spinal 
cord, is probably, like hydrocephalus, an affection of congenital origin 
or of early infancy. As has been already stated, it is sometimes asso- 
ciated with spina bifida; it is sometimes also an accompaniment of hy- 
drocephalus. The canal may be dilated more or less irregularly in its 
whole length, or may present circumscribed dilatations only, and may 
vary from a quarter of an inch to an inch in diameter. 

As regards the aetiology of the chronic hydrocephalus and hydro- 
rhachis commencing in fcetal life or early infancy, we can add but little 
to what has been incidentally mentioned in the foregoing pathological 
account. It is said to occur specially in rickety children, and in chil- 
dren of scrofulous or unhealthy parentage. Its immediate cause is 
probably some chronic inflammation or some condition allied to inflam- 
mation, involving the lining membrane of the affected cavities. 

Symptoms and Progress. — 1. The symptoms of chronic hydrocepha- 
lus are to a large extent comprised in the pathological account of the 
disease which has already been given, or may be surmised from the 
anatomical facts in relation to it there considered. As regards the in- 
vasion of the disease, it may be observed that in some cases the pro- 
gressive enlargement of the head, and the gradual supervention of the 
characteristic physiognomy of the child are the earliest indications of 
the presence of hydrocephalus ; while in some instances epileptiform 
convulsions, repeated from time to time, or other symptoms indicative 
of brain disturbance, precede the appearance of any obvious change in 
the form or size of the skull. We may arrange the symptoms of the 
disease under three heads : first, those that relate to the progressive en- 
largement of the head ; second, those connected with the general nutri- 
tive functions; and, third, those which depend on the involvement of 
the nervous centres. First : the general shape which the head ac- 
quires, and the peculiarities presented by the stretched integuments, 



982 



DISEASES OF THE NERVOUS SYSTEM. 



the eyes, the eyelids, and the face, have already been sufficiently de- 
scribed. We may mention, however, that fluctuation can generally be 
easily perceived in the course of the open sutures, and that these parts 
may often be seen to collapse with inspiration and to become dilated 
with expiration. Occasionally, as in the case of Cardinal, the dilated 
head, like a hydrocele, is to some extent transparent. The increasing 
size and weight of the head render it before long difficult for the child 
to support it, and tend, among other things, to delay the acquisition of 
the power of walking. While the babe is still young it rests its head 
constantly on the pillow, or on the nurse's lap, rolling it about from 
time to time; and when it has acquired the power of walking, it still 
has frequently to lay its head down, or it helps to support it with its 
hands, and, under any circumstances, walks with a slow and cautious 
gait. These latter peculiarities may be continued throughout adult life. 
Second: the general nutritive functions are almost always seriously 
impaired. The child probably takes food well — nay, greedily; but, 
notwithstanding this, it remains undersized and weak, and its face, 
trunk, and limbs become, as a rule, emaciated and shrunken. The 
bowels are often confined. Third : we have pointed out that the 
earliest symptoms of hydrocephalus are not unfrequently epileptiform 
convulsions ; it must be added that convulsions of this kind, or attacks 
of laryngismus stridulus, are very apt to come on at a later period of 
the disease, and that even if convulsions have been absent before, they 
may supervene at the time of puberty, or later. These, however, are 
not the only nervous phenomena present. The child generally gets 
fretful and dull, its vision becomes impaired and sometimes lost, and 
occasionally (but less frequently) it becomes deaf as well; the limbs 
are liable to spasmodic twitches ; and not uncommonly their muscles, 
and more especially those of the lower extremities, become rigid; 
they may also undergo atrophy. With the advance of age, we gener- 
ally find that there is more or less hebetude or idiotcy, some loss of 
memory, some incapability of mental exertion, some special incapacity 
for learning; we probably find, too, that the patient is irritable, pas- 
sionate, or morose. Nevertheless, he is occasionally fairly bright and 
intelligent. 

The duration of life is various. Hydrocephalic foetuses not uncom- 
monly die in the act of being born. Death usually occurs, however, 
during the first or second year, either from convulsions, or coma, or 
some intercurrent disorder. But life may be prolonged for five or ten 
years, or longer. In two cases quoted by Trousseau, from Frank, the 
ages at death were seventy-two and seventy-eight respectively. The 
prospect of life depends, no doubt, to a considerable extent, on the bulk 
to which the skull and its contents have attained, and on whether the 
disease has become stationary or not. It not unfrequently, indeed, be- 
comes arrested at a comparatively early stage, and the patient survives 
with a large head, a protruding forehead, and other more or less obvious 
indications of the affection which he labored under in his infancy. But 
the prospects of life do not depend wholly on these conditions, for the 
man Cardinal, who lived to the age of thirty, had an enormously large 



HODROCEPHALUS AND HYDRORH ACHIS. 



983 



head, and the ossification of his skull was not completed until two 
years before his death. 

2. The symptoms due to dropsy of the ventricles, coming on after 
the consolidation of the skull, are necessarily obscure, and none the less 
so that the dropsy is almost without exception dependent on the pres- 
ence of some other grave lesion which has already produced cerebral 
symptoms. The special symptoms to be expected are those which 
would arise from pressure on the important ganglia situated on the 
floor of the ventricles; or, if the accumulation be acute and abundant, 
and in these respects resembling intraventricular haemorrhage, those 
of almost sudden and profound coma, with general paresis. There is 
probably always more or less impairment of the mental functions, loss 
of memory, dulness and stupidity, attacks of unconsciousness or con- 
vulsions, more or less want of control over the evacuations, and finally 
coma. But, besides these phenomena, there may be more or less 
marked hemiplegia, and not improbably some interference with the 
conductiveness of some of the cranial nerves, or some impairment of 
speech. 

3. The symptoms referable to internal hydrorhachis are also ex- 
ceedingly vague. In some cases there is nothing either in the history 
or in the symptoms to indicate the presence of any affection whatever 
of the cord. In a case of Sir W. Gull's, and in some others that have 
been recorded, dilatation of the canal in the neck induced paresis of the 
upper extremities, with wasting of the muscles. It is natural, indeed, 
to assume that the symptoms of this affection should be those of pres- 
sure on the gray matter of the cord ; and the symptoms which have 
been presented by published cases accord in the main . with this 
assumption. 

The clinical history of hydromeningocele, hydrencephalocele, and 
spina bifida, and the treatment of these affections belong rather to 
surgery than to medicine, and need not further occupy our attention. 

Treatment. — The treatment of dropsical accumulation within the 
brain or cord is exceedingly unsatisfactory. If indeed the dropsy be 
in the adult, and secondary to some other organic lesion, the probability 
is that it will not be diagnosed ; and that if it were diagnosed it would 
not lead us to adopt any special line of treatment. In the chronic 
hydrocephalus of children, however, we so easily recognize the pres- 
ence of the disease, there is such a field for treatment offered by the 
slowness of the case and the gradual evolution of its various symptoms, 
that it is difficult to believe that everything we do must be unavailing. 
Yet this is certainly true of the great majority of cases. The attempt 
has often been made to promote the absorption of the fluid by the 
application of counter-irritants to the surface of the skull, or by the 
compression of the skull effected by means of bandages, or better, by 
the use of long strips of adhesive plaster applied uniformly over its 
surface. Trousseau states that in one of his cases in which he had 
adopted this treatment, sudden death was caused by the yielding of the 
bones of the base of the skull and the discharge of the dropsical fluid 
by the nose. It has been recommended again to tap the distended 
cavities by means of a fine trocar and canula. In using these, the 



984 



DISEASES OF THE NERVOUS SYSTEM. 



puncture should be made vertically, at the edge of the anterior fonta- 
nelle, avoiding, however, the situation of the longitudinal sinus. A 
small quantity of fluid only should be removed at one time, and ex- 
ternal pressure should be used to counteract the removal of pressure 
from within. The operation is not dangerous, and has often been per- 
formed with temporary benefit, although no doubt there is a risk that 
inflammation may follow, or a vessel be wounded. For internal use, 
iodide of potassium, iodide of iron, and mercurials have been employed. 
Sir Thomas Watson suggests, on the recommendation of an old apothe- 
cary of his acquaintance, the exhibition thrice daily of about ten grains 
of a pill made by mixing two parts of crude mercury with one part of 
fresh squills and four parts of conserve of roses. It is stated that per- 
sistence in this for several weeks has cured more than one case of the 
disease. It is nevertheless questionable whether any of the above plans 
of treatment are of real efficacy ; and whether any children, who would 
not otherwise have got well, have recovered under their influence. On 
the whole it seems to us that it is best to aim at promoting the child's 
general health by attention to his diet, and to his secretions, and by 
the use of iron, cod-liver oil, or other tonic medicines calculated to 
fortify his vital powers. 



CHOREA. (St. Vitus's Dance.) 

Definition. — Chorea is a peculiar convulsive disorder, for the most 
part of early life, characterized by disorderly movements, which in the 
first instance are usually unilateral, but soon become general, and 
which tend as a rule to subside spontaneously after a few weeks' 
duration. 

Causation. — This affection occurs mainly among children between 
the ages of five and fifteen, or from the commencement of the second 
dentition to the end of puberty. It is not, however, very uncommon 
to meet with it in persons between fifteen and twenty-five, and, indeed, 
it may occur, but occurs with extreme rarity, at any subsequent period 
of life. Dr. Graves records the case of a chemist who had chorea at 
the age of seventy, and M. Henri Roger that of a lady who was seized 
with it at the age of eighty-three. Chorea attacks females far more 
frequently than males. This preponderance in favor of the female sex 
is manifested even in early childhood, but it becomes more pronounced 
as life advances, and of adults who are attacked very few indeed are 
men. Other predisposing causes are: hereditary influence, childbirth, 
and especially a previous attack of the disease. Trousseau draws at- 
tention to its frequent association with chlorosis; but perhaps the most 
interesting fact in relation to the causation of chorea is the intimate 
connection which it has with articular rheumatism and with cardiac 
disease. Not only does chorea often come on in the course of acute 
rheumatism, not only does acute rheumatism occasionally come on in 
the course of chorea, but a very large proportion of those victims of 



CHOREA. 



985 



chorea whose cases do not fall into either of these categories have suf- 
j fered from acnte rheumatism at some period or other prior to the choreic 
attack. It 1ms further been clearly ascertained that by far the greater 
number of choreic patients present some cardiac defect, that either the 
action of the heart is irregular, or there is what is supposed to be an 
! anaemic murmur at the base, or there is distinct evidence of endocar- 
| ditis, pericarditis, or both, and that this cardiac defect (even if clearly 
i of inflammatory origin) is often met with in cases in which there is no 
history of rheumatism, or comes on during the choreic attack without 
! any associated implication of the joints. Rheumatism, therefore, and 
especially rheumatism attended with pericarditis or endocarditis, must 
be regarded as at least one of the most efficient of the determining 
causes of chorea. Other causes which operate quite independently of 
heart disease or rheumatism are, overwork, anxiety, excitement, and, 
above all, sudden fright. 

Symptoms and Progress. — Chorea generally comes on insidiously, 
; and not unfrequently, before any convulsive movements are recog- 
nized, the child is observed to mope, to avoid its companions, to take 
no interest in its accustomed amusements or games, and to be incapable 
of fixing its attention on its work, of committing lessons to memory, 
or even of readily recollecting. Indeed, there is generally some real 
or apparent mental deficiency, associated with more or less emotional 
disturbance, indicated by a tendency to be capricious and fretful, to 
cry, and to be suspicious or timid. These phenomena may be asso- 
ciated with more or less general loss of health and impairment of the 
nutritive functions. The first indications of the special nature of the 
disease under which the patient is laboring are, usually more or less 
restlessness or fidgetiness, and a certain clumsiness in the patient's 
movements; he cannot sit long in one place; he is constantly shifting 
his position or the position of one or other of his limbs; he stumbles 
* unaccountably in moving about the room or in going up and down 
stairs ; and he has a tendency to spill his tea or coffee, or to drop, or 
to knock against something else, whatever he essays to carry. The 
choreic movements are mostly first manifested upon one side, sometimes 
in the face, sometimes in the hand and arm, less commonly in the leg, 
but soon they involve the whole side in a greater or less degree, and, 
after a variable time, a few days or a few weeks, the affection extends 
to the opposite side of the body, and thus becomes universal, although 
there often still remains more or less distinct preponderance of the 
symptoms on one side. But this mode of access, though the most 
frequent, is by no means invariable. In some cases, when the affec- 
tion comes on in the course of an attack of rheumatism, no obvious 
prodromal symptoms are presented. And sometimes, especially when 
the disease is induced by violent emotion, its onset is sudden, and the 
symptoms may be general from the beginning. 

The phenomena of the fully-developed affection, although varying 
largely in degree, differ but little in kind, and are for the most part 
exceedingly characteristic. The convulsions affect, in a greater or less 
degree, the whole body. They are remarkable for their disorderly 
character ; they are not rhythmical, neither do they consist simply in 



986 



DISEASES OF THE NERVOUS SYSTEM. 



alternate flexions and extensions, but they consist in sudden impulsive 
movements, succeeding one another at irregular intervals, and involv- 
ing now one group of muscles, now another, now one part of the body, 
now another, now several concurrently. The convulsions generally 
subside in some degree when the patient is sitting or lying down, and 
(if they are not very violent) he is sometimes able to restrain them for 
a few moments, but they become aggravated whenever he endeavors 
to execute voluntary movements, whenever anything occurs to excite 
him, whenever he feels that he is being observed. It hence happens 
that the medical attendant rarely sees him at his best. The choreic 
phenomena cease during sleep and under the influence of chloroform. 
The affection of the muscles of the face induces constant contortions of 
the features; the eyebrows are at one time elevated and the forehead 
thrown into transverse wrinkles ; at another time the brows are knit ; 
the eyes move suddenly and without purpose in various directions ; 
the mouth is at one time opened, at another closed, and drawn into 
various odd forms by the influence of the orbicularis and surrounding 
muscles. The face, moreover, wears a strangely vacant imbecile as- 
pect. The tongue shares in these tumultuous movements. If the 
patient be asked to put it out, he opens his mouth wide and protrudes 
it with a jerk, and then as suddenly withdraws it, the mouth and jaws 
closing upon it with sudden violence. If he endeavor to answer ques- 
tions, the convulsive movements of the face and mouth become greatly 
aggravated, and he has extreme difficulty in articulating his words, 
which come out in driblets as it were, slurred over, or uttered with a 
peculiar drawl, hesitation, or stammer. The difficulty of speech de- 
pends partly on the convulsive action of the lips and tongue, but not 
unfrequently also on spasmodic affection of the larynx and of the re- 
spiratory muscles. In consequence of this latter complication, the 
patient sometimes draws his breath suddenly through the laryngeal 
orifice with a strange sound, and in some cases, even when no such j 
attempt is being made, odd croaking or grunting noises are thus from 
time to time produced. The actions of the muscles of the head and 
neck are probably as incoherent as those of the face, so that the head 
is sometimes jerked to one side, sometimes to the other, or thrown dis- 
orderly into various odd positions. No parts usually manifest choreic 
phenomena more strikingly than the upper extremity ; all its segments 
are involved in a greater or less degree ; the patient hitches his shoul- 
der; he moves his upper arm to and from his side; his forearm be- 
comes flexed, extended, supinated, pronated ; his hands and fingers 
execute the most grotesque and incoordinate movements. The gen- 
eral movements of the limb, when the patient uses it — when, for ex- 
ample, he endeavors to raise a glass of water to his lips — are curious 
to watch. By an effort of the will (if the case be not exceedingly 
severe) the glass ultimately reaches its destination, but it reaches it 
probably after many failures ; its progress is arrested, not by a series 
of undulatory, tremulous, or backward and forward movements of the 
limb, but the different segments are suddenly and violently plucked, 
as it were, by some invisible power, first in one direction, then in an- 
other, in the line of the intended movement, or in direct opposition to 



CHOREA. 987 

! it, or at right angles with it. The primary movement is overlaid, as 
it were, during its course, with innumerable uncontrollable secondary 
movements, which retard it, aggravate it, and distract it. The lower 
extremities are affected similarly to the arms. They are moderately 
quiet when the patient is at rest, but as soon as he begins to use them, 

j as soon as he begins to walk, their movements become incoordinate, 
jerky, tumultuous. To quote Sir Thomas Watson's words : " When the 
patient intends to stand or sit still, her feet scrape and shuffle on the 
floor, or one of them is suddenly everted and then twisted inwards, or 
perhaps is thrown across the other, and if she endeavor to walk, her 
progress is indirect and uncertain, she halts and drags her leg rather 
than lifts it up, and advances with a rushing or jumping motion by fits 
and starts." The muscles of the trunk partake in the general convul- 
sive movements, and the body is consequently twitched and contorted 
with sudden violence into all kinds of odd and unaccountable posi- 
tions. It must be added that mastication and deglutition are often 
rendered difficult by the spasmodic movements of the muscles engaged 
in these operations, that respiration is frequently interrupted and ren- 
dered irregular, jerky, and noisy, by involvement of the diaphragm, 
and that sometimes, in severe cases, the sphincters of the rectum and 
bladder relax, and the evacuations escape involuntarily. In mild cases 
the patient is able to walk about, though with more or less difficulty or 
clumsiness, and it may be to feed and dress himself. In more severe 
cases locomotion is impossible, and he has to be confined to his bed ; 
he becomes, moreover, quite incapable of using his hands for any pur- 
pose. In its worst form the condition of the patient is miserable in 
the last degree, and pitiable to behold. His features and his head and 
neck are in constant motion ; his arms are flung out first in this direc- 
tion and then in that, his fingers and hands meanwhile executing the 
most varied and fantastic movements ; his lower extremities are prob- 
ably little less violent in their movements than the arms ; and the 
trunk is constantly being twisted about in bed, now into the prone 
condition, now into the supine, is now doubled up, now straightened 
out again, now caught by some strange contortion. 

The phenomena above described are not, however, the only nervous 
phenomena which attend chorea. There is always some impairment 
of the strength of the affected muscles, some paresis, a fact especially 
easy of recognition in cases of unilateral chorea. In some cases indeed, 
the convulsive phenomena may be replaced by more or less complete 
hemiplegia or even paraplegia. Sometimes the hemiplegic or para- 
plegic symptoms precede the onset of the choreic movements. More 
frequently they come on in the course of the disease and supplant 
them. Some impairment of sensation is also observable in the great 
majority of cases; and its degree has more or less relation to the 
severity of the convulsions or to the degree of the paralysis which is 
present. The fatuous aspect of the patient in the early stage of chorea 
has already been referred to ; this aspect continues and even becomes 
aggravated during the continuance of the disease. No doubt it largely 
depends upon the various spasmodic movements in which the muscles 
of expression and those that move the eyeballs are implicated, but 



988 



DISEASES OF THE NERVOUS SYSTEM. 



there is good reason to believe it is to some extent governed by the fact 
that the intelligence does actually fail to a greater or less extent during 
the presence of the malady. Emotional sensibility, on the other hand, 
is somewhat exalted. Sometimes the eyesight fails. 

Subordinate symptoms of more or less importance are apt to attend 
the progress of chorea. The patient's appetite is often bad, or capri- 
cious, or fails. His bowels are confined. His nutrition becomes im- 
paired. He suffers from palpitation, and, as has been already pointed 
out, he is liable to functional or organic disease of the heart, either of 
which may supervene in the course of his attack. There is a striking 
absence of febrile symptoms during the progress of the disease. 

The issue of chorea is in the vast majority of cases favorable. Some- 
times (if for example the choreic movements come on in the course of 
acute rheumatism and involve one arm only) the patient recovers in 
the course of a few days. More commonly the disease continues for a 
period varying between four or five weeks and three months. In some 
instances it is prolonged for two or three years or more. But in these 
cases it is usually continued by successive relapses, each coming on be- 
fore the symptoms of the preceding attack have wholly disappeared. 
Indeed, patients who have had one attack of chorea are peculiarly 
liable to subsequent attacks, which come on at irregular periods and 
under the slightest provocation. Very rarely, indeed, chorea lasts for 
many years or for a lifetime. When the disease is fatal, it rapidly 
assumes the aggravated proportions which have been above described. 
The spasms are incessant; their violence and continuance prevent 
sleep, or allow only of occasional short snatches of sleep, and they in- 
terfere seriously with the ingestion of food, and thus rapidly induce 
mental and bodily exhaustion. Further, the evacuations escape un- 
consciously, or at all events are uncontrolled ; and partly on this ac- 
count, partly on account of the constant friction to which the trunk 
and limbs are subjected in consequence of their never-ceasing move- 
ments, the skin becomes chafed in innumerable places, and bedsores 
form over the various prominences, more especially over the elbows, 
hips, and sacrum. It may be added that the child bites its lips until 
they bleed, and that very frequently the red portions of both lips be- 
come split by numerous deep vertical fissures. Death, which may be 
preceded by delirium, is generally due to asthenia. But its immediate 
cause may be the supervention of erysipelas or the consequences of 
heart disease. 

The recovery from chorea (putting cardiac disease out of the ques- 
tion) is generally in the long run complete. The patient regains his 
muscular strength, and his intelligence is restored to him unimpaired. 
But it is not always so ; occasionally he remains more or less feeble- 
minded, or he even becomes insane, or lapses into a fatuous condition. 
In some cases, too, the implicated muscles remain enfeebled ; and they 
may then undergo slow contraction or atrophy, or both. In a chronic 
case which has been under our observation, and in which the general 
symptoms were undistinguishable from those of genuine chorea, the 
choreic movements of the lower extremities were associated with 
marked rigidity of the muscles, some degree of flexion at the hip and 



CHOREA. 



989 



knee-joints, with overlapping of the knees from the preponderant 

i action of the adductors of the thighs, and a tendency to talipes equino- 
varus — facts which seem to indicate that degenerative changes of the 
lateral columns of the cord had supervened. 

Morbid Anatomy and Pathology. — The pathology of chorea is con- 
fessedly obscure; it is not known either what part of the central nerv- 

j ous organs is the seat of disease, or what is the nature of the morbid 

\ process going on in the affected parts. The fact of its unilateral com- 
mencement and generally unilateral tendency points to disease either 

! of the crus cerebri, or of the corresponding corpus striatum and optic 
thalamus, or of the cerebral hemisphere. But against this view must 
be placed the generally well-marked implication of the muscles of the 
eyeballs, and of those supplied by the upper portions of the facial 
nerves, which, as is known, are little if at all involved in the paralyses 
which attend softening, effusion of blood, and other organic lesions of 
these parts. The tendency of the affection to extend to the opposite 

j side of the body and to implicate the muscles of deglutition and respi- 
ration, is also adverse to this hypothesis. The convulsive movements, 
which have a distinct resemblance in many points to those which at- 
tend locomotor ataxy, might well seem to indicate disease of the pos- 
terior columns of the cord as the cause of choreic convulsions. But 
affections of the cord are rarely unilateral, and when unilateral (if sen- 
sation and motion be both affected) the impairment of sensation impli- 

, cates one side of the body, while that of sensation implicates the other; 
whereas in chorea the impairment of sensation and of motion usually, 
if not always, attack the same regions. Then as regards the nature of 
the disease, its frequent connection with rheumatism and cardiac dis- 
ease has suggested at least two hypotheses : one, originating with Dr. 
Kirkes, and since ably supported by Dr. Hughlings Jackson, is to the 
effect that the symptoms are clue to the obstruction by minute emboli 
of the smaller branches of the arteries supplying the corpus striatum 
and contiguous parts, with consequent scattered minute patches of con- 
gestion and softening. The objections, however, to this view are 

i obvious. Obstruction of the arterioles has been observed only in a 
very small number of cases, and it is doubtful if in these the obstruc- 
tions were embolic or thrombotic. Besides which, it is not only dif- 
ficult to believe that showers of minute emboli should be distributed 
throughout the minute vessels supplied to one corpus striatum only, 
and that at some later period there should be a similar limitation of 
such embolic patches to the region supplied by the middle cerebral 
artery of the other side ; but it is difficult also to understand why large 
emboli should not be occasionally intermingled with the smaller ones, 
and cause sudden hemiplegia by obstructing a large vessel, and why 
the small emboli shed simultaneously should not become blended by 
fibrinous coagulation around them into one or two concrete masses. 
[There are several other objections to this theory. Among them is the 
absence of the disordered movements during sleep. If these are really 
the consequence of embolism of the minute cerebral arteries, the irrita- 
tion upon which they depend must be a constant one, allowing of no 
remission. It is also difficult under this theory to explain the sudden 



990 



DISEASES OF THE NERVOUS SYSTEM. 



occurrence of the symptoms of this disease in the midst of what ap- 
pears to be good health after a powerful emotion, such as fright, or 
their abrupt cessation either as a result of treatment or from some other 
cause. Another fact which also tends to disprove this theory is the 
more frequent occurrence of chorea among girls than among boys, 
while the cause to which this is traced — vegetations upon the valves — 
must, as a consequence of rheumatism, be more common in the male 
sex. This is an objection which cannot be entirely gotten over by 
ascribing the greater frequency of chorea in girls to the greater excita- 
bility of their nervous systems.] Another view is that the same dis- 
ease which affects the valves of the heart or the joints in rheumatism 
attacks also the smaller vessels or the ultimate tissue of the central 
nervous organs, a view which might well explain the supervention of 
cardiac disease on chorea, as well as the dependence of chorea on rheu- 
matic fever. A main objection to this view is the fact that hitherto it 
has been simply conjectural and unsupported by any anatomical evi- 
dence. Moreover, it fails, equally with the embolic hypothesis, to ex- 
plain those cases which are due to fright or other powerful emotions, 
and in which the heart remains perfectly sound. 

It seems to us, however, that the clinical phenomena of chorea can- 
not possibly be referred to affection of any circumscribed region of the 
nervous centres ; and that, whether the seat of disease be thus limited 
or not, the embolic hypothesis is altogether inadequate as an explana- 
tion of the nature of the morbid processes to which the clinical phe- 
nomena are linked. The symptoms are partly intellectual, partly 
emotional, partly referable to the functions of the voluntary muscles, 
partly referable to the cutaneous sensibility, and partly referable also 
to the bulbar nerves, which subserve articulation, deglutition, respira- 
tion, and the motor function of the heart; they would seem, therefore, 
to be connected at the same time or successively, and in different 
degrees, with the cerebral convolutions, the ganglia at the base, the 
pons and medulla, and the spinal cord. The valuable paper recently 
read by Dr. Dickinson before the Medico-Chirurgieal Society is 
strongly confirmatory of this view. He shows from the results of 
careful post-mortem examinations made on several fatal cases of chorea, 
that there is a general tendency to dilatation of the smaller vessels and 
more especially of the arteries throughout the substance of the brain 
and cord ; that the arterial dilatations are attended with exudation 
into the tissues immediately surrounding them, and in some cases with 
small haemorrhages indicated by the presence of blood-crystals and the 
like, and in some with limited patches of sclerosis; that these changes 
are most advanced in the corpora striata, in the nervous matter in the 
neighborhood of the trunks of the middle cerebral arteries, and in the 
posterior and lateral portions of the gray matter of the cord, mainly at 
the upper part ; and further, that in all these regions the morbid con- 
ditions tend to be symmetrically arranged. And on the basis of these 
facts, and admitting that chorea is generally associated with rheuma- 
tism, in the larger proportion of cases with heart disease, and in some 
cases with no inflammatory or structural disease of any organ, he 
comes to the conclusion (in which we are disposed fully to concur) that 



CHOREA. 



991 



chorea depends " on a widely-spread hyperemia of the nervous centres, 
not due to any mechanical mischance, but produced by causes mainly 
of two kinds — one being the rheumatic condition, the other comprising 
various forms of irritation, mental and reflex, belonging especially to 
the nervous system." The tendency which the vascular changes have 
(on Dr. Dickinson's showing) to induce sclerosis in the tissues which 
surround the vessels well explains the wasting of the muscles, rigidity 
of the limbs, and permanent paralysis, which occasionally complicate 
chorea or supervene upon it. 

Treatment. — For few diseases have so many specific remedies been 
vaunted as for chorea; yet few diseases are really so little amenable to 
treatment. It must never be forgotten, in weighing the value of 
medicines in this affection, that the great majority of cases tend to get 
well spontaneously in the course of a few weeks. Sydenham recom- 
mended bleeding and tartrate of antimony, and cured his patients by 
these means; and even Sir Thomas Watson advocates local bleeding 
when there is a fixed pain in the head. Large doses of antimony, 
indeed, have been strongly recommended by many physicians. Iron 
is a favorite remedy ; so is arsenic; and so also is sulphate of zinc, 
given in doses, to commence with, of a grain or two three times a day, 
which are slowly increased by successive increments, until from 20 to 
40 grains are given at a time. Iodide of potassium is lauded by some ; 
bromide of potassium by others ; phosphorus by others. Of medicines 
derived from vegetable sources we may name turpentine, strychnia, 
cannabis ,Indica, opium, belladonna, and various antispasmodics. 
Exercise, frictions, and cold baths, more especially shower-baths, have 
all their advocates. We must confess that in our own opinion few, if 
any, of the above remedies have any real influence over the course of 
the disease; if, however, we have any bias, it is in favor of arsenic, 
given in small doses, and continued for some length of time. [An- 
other plan of giving arsenic, which has a reasonable degree of success 
in its favor, is to gradually increase the dose until the amount which 
the patient can bear without its provoking vomiting or nausea is at- 
tained. This amount should be continued until the cure is complete.] 
We believe, however, that real benefit does accrue in a considerable 
number of cases from attempts made to improve the general health ; 
that in this point of view, tonics (among which iron holds an important 
place) are useful, as also are careful attention to hygienic measures, 
good wholesome diet, early hours, avoidance of excitement, gentle 
exercise, cold or tepid bathing, and change of scene and air. It must be 
added that our treatment may often be usefully directed by the nature 
of the malady (if any) with which the chorea is associated ; and that 
thus, when rheumatism is present, or chorea is a legacy left by rheu- 
matism, antirheumatic treatment may be of great service. In those 
severe cases in which the convulsive movements are incessant, and the 
patient has little or no rest, and death consequently threatens, narcotics 
and- stimulants would seem to be indicated. The inhalation of chloro- 
form arrests the convulsive movements so long as the patient is under 
its influence; opium or morphia or chloral in large doses has the 
same effect. But it must be admitted that, notwithstanding the tern- 



992 



DISEASES OF THE NERVOUS SYSTEM. 



porarv ease they give, the progress of the disease towards its fatal end 
is rarely, if ever, retarded by their use. The patient should then be 
supported by food and stimulants. Further, every precaution should 
be taken to prevent the patient from injuring himself in his contor- 
tions, and all sores that form upon the surface of the skin should be at 
once treated, and protected from further injury. 

It may be pointed out, in conclusion, that chorea is apt to spread 
among children, apparently by imitation ; that choreic patients are 
often rendered worse by their association with patients of the same 
class ; and that hence precautionary measures directed against such 
accidents should be taken. 



EPILEPSY. ECLAMPSIA. INFANTILE CONVULSIONS. 

Epilepsy. {Morbus comitialis vel sacer.) 

Definition. — It is difficult, if not impossible, so to define epilepsy as 
within the limits of a mere definition to include all the varieties of 
form which it assumes. Speaking generally, it is a functional disorder 
of the nervous centres, characterized by sudden seizures of temporary 
duration and occurring at irregular intervals, in which the patient 
either loses consciousness or presents some other form of mental dis- 
turbance, or has tonic or clonic convulsions, or all of these phenomena 
in sequence. For a true conception of the disease, it must be under- 
stood that, however mild the attacks may be, all the phenomena which 
have been enumerated are potentially present in them, and may be ex- 
pected to occur in combination during the progress of the disease. 

Causation. — The causes of epilepsy are very obscure. The disease 
has been attributed to all sorts of circumstances which have probably 
little or no influence in its production. Among those to which most 
importance has been attached may be mentioned sudden fright, the 
witnessing of an attack of epilepsy, long-continued anxiety, overwork, 
drink, abuse of absinthe, and venereal excesses, especially masturbation. 
The importance, however, of even these as exciting causes has been 
greatly overestimated. It is considered by Trousseau that the real 
share of each one of them (excepting fright) in the production of the 
disease is yet to be proved ; and Russell Reynolds remarks of excessive 
venery and of masturbation, that far too much importance has been 
attached to them. Hereditary predisposition, on the other hand, ex- 
erts a remarkable influence over the development of epilepsy. It is to 
be observed, however, that it is not so much epilepsy itself which is 
hereditary (although no doubt it is so in a very high degree), as that 
epilepsy becomes hereditary in families, among the members of which 
neuroses, such as epilepsy, insanity, hysteria and the like, prevail. It 
is not uncommon to find in such families that several of the children 
are epileptic, or that one is epileptic, one suffers from chorea, one is an 
idiot, and so on. But the predisposition to epilepsy may be acquired ; 



EPILEPSY. 993 

for it is certain that many of those persons who subsequently become 
epileptic have suffered in infancy from convulsions, which were induced 
by teething or other accidental circumstances. Epilepsy occurs pretty 
equally in both sexes. The first attack may come on at any period of 
life; in early childhood or extreme old age; but it occurs far more 
! frequently between the ages of ten and twenty (more precisely, per- 
I haps, during the time of puberty) than it does at any other period of 
| life. Dr. Reynolds points out that there is comparative immunity be- 
tween the ages of twenty-five and thirty-five ; but that the outbreak 
i of the disease becomes comparatively frequent again about the age of 
j forty. After this time its primary appearance is extremely rare. 

Symptoms and Progress. — The phenomena of epileptic attacks are so 
; various, they differ so widely from one another in different cases, both 
in their characters and in their grouping, that it is impossible to give 
! a comprehensive, and at the same time graphic, account of them, ex- 
cepting by the aid of illustrative cases. Our space forbids the adoption 
of this course. We shall, therefore, begin with the description of a 
typical attack of the disease, and then discuss the variations to which 
attacks are liable. 

The epileptic fit, though often quite sudden in its invasion, is not 
unfrequently preceded by a well-marked prodromal period, lasting in 
different cases from a day or two to a few seconds. Under any circum- 
stances, the onset of the fit Is quite sudden ; the patient probably utters 
a cry, loses consciousness, and, if standing, falls down as if shot, on his 
face or on the back of his head; his muscles become rigid, especially, 
perhaps, those of one side, and at the same time slowly contract ; and 
respiration ceases. After these phenomena, which, constitute the first 
stage of the attack, have lasted for a few seconds, the second stage 
supervenes. This is characterized mainly by return of respiration, 
lividity of surface, distension of the veins of the head and neck, clonic 
spasms, which are mostly unilateral, biting of the tongue, and contin- 
uance of unconsciousness. At the end of a minute or two this stage 
also comes to a conclusion, the lividity disappears and the convulsions 
cease, but the patient probably still continues insensible; presently, 
how T ever, consciousness returns in some degree, and he either rapidly 
recovers, or remains confused or maniacal, or in a state of stupor, for 
some hours, or it may be a day or two, before complete recovery ensues. 

The prodromal period is present probably in about half the total 
number of cases, and if present in one attack is most likely present in 
other attacks occurring in the same patient. Moreover, under such 
j circumstances the premonitory symptoms continue probably, at any 
I rate for a time, of the same kind. Those which precede the attack by 
some hours or a day or two are the least common, and although per- 
! haps apparent enough to the patient or his friends, are on the whole 
slight in degree and vague. They consist, for the most part, in some 
modification of the patient's intelligence, feelings, or habits; he gets 
! dull and incapable of mental exertion or of attention to business, sullen 
| or low-spirited ; or his manner and conversation become sparkling and 
j lively, and his spirits unaccountably buoyant and jovial — he may even 
| be furiously maniacal; or there is simply something in his look — a 

63 



994 



DISEASES OF THE NERVOUS SYSTEM. 



wildness in his eye, or a dulness and heaviness of expression — which is 
not natural to him. The more characteristic premonitory symptoms 
are those which precede the fit by a few minutes or a few seconds only. 
They are remarkably various. In some cases they consist in the spas- 
modic contraction of certain muscles: the expressional muscles of one 
side of the face twitch ; or the hand and arm are convulsed, and are 
gradually carried upwards towards the face; or the lower extremity is 
equivalently affected ; or the muscles of one side of the head and neck 
gradually contract and carry the face over the opposite shoulder; or 
the muscles of several or of all these regions are simultaneously in- 
volved. Sometimes the epileptic fit is preceded by vertigo, or sickness, 
or by severe pain or some undefinable sensation referred to the head, 
throat, chest, abdomen, or some other part. Not unfrequently the 
premonition is furnished by what has been termed the epileptic aura — 
a sense of coldness, heat, or pain, starting from some point, say the 
finger or the toe, or the abdomen, or the chest, or it may be from the 
seat of some former injury — which seems gradually to ascend until it 
reaches, as the case may be, the epigastrium or the precordial region, 
or the head, when insensibility suddenly supervenes. In some cases 
the attack is ushered in by some hallucination of the senses; the pa- 
tient perceives some peculiar smell ; or he hears strange sounds, and, 
it may be, voices; or he sees definite forms before his eyes — animals, 
departed friends, witches, devils. Not unfrequently, again, the pre- 
monitory symptoms consist in some odd mental disturbance: the 
patient experiences a sudden horror or trouble, or finds himself engaged 
in some special train of thought, or perplexed by some problem or the 
plot of some story or some strange combination of circumstances. It 
is curious that these mental perplexities which seize upon the patient 
are often entirely forgotten after the occurrence of the fit, yet that the 
same perplexity is repeated (exactly as the drawing up of the arm or 
the occurrence of an aura is repeated in other cases) before every epi- 
leptic attack. 

The most constant feature of the first stage of the attack is the 
sudden onset of absolute unconsciousness. This may be momentary 
only, or may be prolonged throughout the whole of the first and second 
stages, and for two or three minutes or more. As we shall afterwards 
show, it is sometimes absent. This unconsciousness while it lasts is 
profound; the patient neither sees, nor hears, nor feels, nor can be 
roused by any means at our command. The convulsions which attend 
this stage are tonic; they consist in the supervention in the affected 
muscles of great rigidity, attended in the first instance with fibrillar 
movements, and a tendency for certain muscles gradually to overcome 
their antagonists. They are rarely general, or if general they affect one 
side more powerfully than the other ; they are in fact almost always 
unilateral, and sometimes limited to the side of the face, or head and 
neck, or to the arm. The face becomes hideously distorted, the tongue 
probably thrust between the teeth ; the head, from contraction of the 
sterno-mastoid and other muscles of the neck, drawn down obliquely on 
one side, the face being thrust over the opposite shoulder; the trunk 
contorted ; and the arm or leg flexed or extended. At the same time 



EPILEPSY. 



995 



the respiratory muscles and those of the larynx become fixed, and the 
acts of respiration entirely cease. These spasms are sometimes wholly 
absent. The epileptic cry which ushers in the attack occurs only in 
I a limited number of cases. It varies in character, is sometimes a loud 
shriek, sometimes a hoarse groan ; and is usually very distressing to 
! hear. It occurs (as Dr. Reynolds points out) once only, and appears 
| to depend on the sudden emission of breath through the contracted 
i laryngeal opening by the action of the contracting expiratory muscles. 
I The pupils are dilated and insensible to light. If the patient be closely 
! observed at the onset of his attack, his face will usually be seen to be 
I suddenly overspread with a deathlike pallor, which persists for a few 
seconds, but gradually, during the progress of the first stage, becomes 
replaced by redness and turgidity. In some instances no change 
whatever of color can be discovered. In association with the phe- 
nomena here enumerated there is usually extreme feebleness of pulse. 
Although the patient generally falls with sudden violence, he some- 
times slips down quietly, almost as if by design ; and if the loss of con- 
sciousness be momentary only he sometimes remains motionless, stand- 
ing or sitting, or merely staggers. The first stage usually lasts from 
ten to thirty or forty seconds. 

The second stage is attended with continuance of unconsciousness. 
The face has usually by the time of its commencement become livid 
and bloated, and the veins of the head and neck distended ; but this 
lividity and overdistension of the vessels slowly subside during its 
continuance. The tonic spasms cease, to be replaced by clonic spasms. 
These, which consist in alternate powerful contractions of flexors and 
extensors or other groups of antagonistic muscles, may be general ; but 
they are more commonly one-sided and limited to those parts which 
had previously been the seat of tonic contraction. The pupils oscillate, 
the eyelids and muscles of expression work, the mouth is alternately 
opened and closed with violence, and the protruded tongue, caught 
between the teeth, is apt to get severely bitten; the muscles of the head 
and neck and those of the trunk are convulsed; and the arm and leg 
execute powerful movements of extension and flexion. At the same 
time probably the fseces and the urine are discharged involuntarily. 
The respiratory acts are resumed at the commencement of this stage, 
and during its course are violent, jerky, noisy, and labored. The skin 
is cold; profuse perspirations break out; the pulse is full; the heart 
beats violently. Mucus accumulates in the mouth and fauces, and 
mingled with the blood which comes from the bitten tongue, escapes 
i from the lips. The symptoms of this stage, violent in the beginning, 
| gradually subside; and at the end of a few seconds, a minute, or at 
most two or three minutes, the patient draws a deep sigh, and the 
second stage is completed. 

The condition of the patient in the third stage varies. Sometimes 
he recovers almost instantaneously, and appears to be at once in his 
normal health; but more commonly he lies for some minutes or for 
half an hour in a condition of profound coma, from which it is impos- 
sible to arouse him. Sooner or later, however, consciousness slowly 
returns; he opens his eyes and gazes stupidly or wildly about him; he 



996 



DISEASES OF THE NERVOUS SYSTEM. 



1 



tries to speak, bat mumbles unintelligibly or incoherently, or fails to 
produce any articulate sound ; he tries perhaps to get up, and his move- 
ments and demeanor resemble those of a drunken man ; sometimes 
he becomes wildly maniacal, sometimes falls into a state of trance or 
ecstasy. It not unfrequently happens that the patient lapses into a 
more or less profound sleep, interrupted it may be from time to time 
by slight convulsive twitchings. Muscular weariness, a sense of general 
bruising, headache, vertigo, restlessness, severe mental or emotional 
disturbance are apt to remain for some hours or for a few days after the 
fit. It must be added that after the attack the patient often passes a 
large quantity of limpid urine; and that, owing to the extreme disten- 
sion of the vessels of the head and neck and upper part of the trunk, 
minute extravasations of blood are apt to be produced during the fit, 
and the surface of these parts to become more or less thickly studded 
with persistent hemorrhagic points, or petechia?. 

The above account applies to those fits, typical in their severity and 
in the sequence of their phenomena, to which the names epilepsia gra- 
vior and haut mal have been given. But in a large number of cases 
either the fit does not pass beyond the prodromal stage; or various of 
the stages are absent, or so rapidly completed, or so blended with one 
another that they escape observation ; or some of the features of the 
malady are aggravated ; or new features are superadded. Most of these 
attacks come under the denomination of epilepsia mitior, 'petit mal, or 
epileptic vertigo. 

In some cases the patient is affected with an occasional sudden spasm 
of one side of the face, or of one stern o-mastoid ; or his hand closes, 
and the arm is gradually drawn up or flexed ; or he experiences some 
one of those sensory hallucinations which have been previously enu- 
merated ; or he has an aura, or a sudden attack of headache, giddiness, 
sickness, or faintness. In other words, he is attacked with some one 
of the prodromal symptoms which are known to usher in epilepsy. 
Now it does not at all necessarily follow that the sudden occurrence of 
such phenomena, or even their occasional repetition, proves that the 
patient is epileptic ; but it is certain that of those persons who suffer 
from them, some become epileptic sooner or later ; and that those epi- 
leptics whose fits are preceded by warning symptoms not unfrequently 
have such warnings without fits following them. There can be no 
doubt that such attacks must, under these circumstances, be regarded 
as epileptic. They are, in fact, abortive epileptic fits. In some in- 
stances the patient's seizures consist in little more than a momentary 
interruption to the continuity of his thoughts. He is engaged in talk- 
ing, and suddenly for a second or two becomes quiet, and then resumes 
the thread of his conversation as if nothing had occurred ; or instead 
of ceasing to speak he may utter some incoherent sounds, or words and 
expressions utterly alien to the subject on which he was engaged. If 
the patient be closely observed at this moment, his pupils will probably 
be seen to dilate, his face to become momentarily pale, and then perhaps 
with returning consciousness a little more congested than natural. 
During the momentary attack the patient may become absolutely un- 
conscious, and his mind may be a blank; or, although unconscious to 



EPILEPSY. 



997 



everything about him, he may be the subject of a sudden trouble, per- 
plexity of mind, or horror — some momentary nightmare, as it -were. 
Sometimes the patient utters a shriek and reels or staggers, or performs 
a rotatory movement, and then without falling to the ground recovers. 
Sometimes he is seized with unconsciousness, lasting for a few seconds, 
or for a minute or more, and remains sitting or standing, or in what- 
| ever other position the fit surprised him in, his features meanwhile 
I being perfectly passive or presenting convulsive twitchings. In some 
j cases the wholly unconscious patient will go on during his unconscious- 
! ness with the work in which he was engaged at the time of seizure ; if 
walking he will continue to walk, if running he will go on running. 
Trousseau mentions the case of a young amateur violinist who, during 
attacks of short duration, would go on playing with perfect accuracy as 
if he were still in his ordinary senses. There are other cases, again, in 
which the patient, during his attack of unconsciousness, performs 
strange actions, which have nevertheless an aspect of purposiveness 
I about them, but of which he has no recollection whatever when con- 
sciousness returns. They would seem in fact like the translation into 
action of the fragment of a dream. Thus, sometimes, while walking, 
perhaps in the street, he will suddenly begin to run rapidly, avoiding 
all obstacles, and then coming to himself discovers himself unaccount- 
ably far from his destination or from the place at which he lost his 
senses. Trousseau cites the case of a magistrate who, in such an at- 
tack, suddenly left the court over which he was presiding, went into 
the council chamber, made water in a- corner of the room, and returned 
to the court entirely ignorant of the strange act that he had committed. 
Sometimes the patient will dance or sing, or peer about in various 
directions as if in search of something which he had lost or mislaid. 
But perhaps the most important, if not the most remarkable, of these 
aberrant forms of epilepsy are those in which the patient is seized with 
sudden and unaccountable fury, tears his clothes, or destroys anything 
that is near him, belabors the friend or the servant that is with him, 
or rushes out of the house and attacks the first stranger that he meets, 
or jumps from the window, or in some other way maims or kills him- 
self, and moreover not unfrequently accomplishes such acts with appar- 
ent definiteness of purpose. Thus a husband, waking apparently out 
of his sleep, will beat or strangle his wife with the utmost ferocity ; a 
man walking along the street will, at the moment when the impulse is 
upon him, make an unprovoked and violent onslaught on whoever 
chances to come near. Now it must be borne in mind that in all the 
varieties of seizure which have been passed in review, in all the differ- 
ent forms, that is to say, of epileptic vertigo which we have been con- 
sidering, the only appreciable part of the attack may be the temporary 
unconsciousness, or delirium, together with the various specific motor 
phenomena which have been enumerated, and the utter unconscious- 
ness or forgetfulness of what has passed in the attack. There may be 
no premonitory symptoms, no tonic or clonic convulsions, no change 
of color, no succeeding bodily or mental suffering. On the other 
hand, careful observation will often reveal the presence in a more or 
less modified form of some of the more ordinary features of the typi- 



998 



DISEASES OF THE NERVOUS SYSTEM. 



cal epileptic fit. There may be slight premonitory symptoms ; and 
there is generally a sudden pallor or ghastliness at the commencement 
of the attack, soon followed by more or less redness and lividity, and 
in connection therewith dilatation of pupils, rolling of the eyes, or 
twitching or more violent convulsive movements of the muscles of the 
face or one of the limbs; and, further, vertigo, confusion of mind, or 
other such conditions may remain for a longer or shorter time after the 
subsidence of the fit. 

The first epileptic fit may also be the last; but in the great majority 
of cases it forms the prelude to subsequent attacks, which may come 
on at various intervals for months or years or during the whole subse- 
quent lifetime of the patient. In some cases the fits recur with more 
or less irregularity at intervals of a week, a month, two or three months, 
or a year, or more. There may then be a single fit at each recurring 
period, or there may be two or three, or a dozen, or more, succeeding 
one another more or less rapidly during a period of twelve or twenty- 
four hours. In some instances the fits occur habitually many times 
during the day and night. It not unfrequently happens that, as the 
general health improves or age advances, the fits become less and less 
frequent, and at length recur at irregular intervals of years, or disap- 
pear altogether. It must be borne in mind, however, that those who 
have once been epileptic, even if five, or ten, or a dozen years have 
passed since the last attack, are still not unlikely to suffer from a re- 
lapse ; and, again, that patients whose fits have hitherto occurred at long 
intervals only not unfrequently suffer from aggravation of the disease: 
the fits rapidly increasing in frequency, and recurring in large numbers 
day and night for weeks together. Sometimes when the attacks follow 
one another very rapidly, the patient falls into the condition which is 
known as the status epilepticus — a condition in which he remains in- 
sensible for many hours, sometimes for a day or two, and which has 
often been referred to the persistence of a single fit ; it is, however, 
made up of a succession of fits, linked together by persistent epileptic 
coma. 

Convulsive fits recur as a rule much less frequently than the attacks 
of epileptic vertigo ; although when they do recur at long intervals 
they are especially liable to be repeated several times within a limited 
period. Epileptic vertigo may come on habitually twenty, thirty, or 
forty times, or even as many as a hundred times in the day. Accord- 
ing to Dr. Reynolds, cases of the haut mal are nearly twice as common 
as cases of the 'petit mal ; there can be little doubt, however, that the 
petit mal is much more frequent than is generally supposed, and that 
many persons accounted healthy, and who never consult a doctor, are 
liable to occasional slight seizures. Attacks of the haut mal not un- 
frequently, however, alternate with those of epileptic vertigo ; and still 
oftener patients who are subject to the former have abortive seizures 
represented by the aura only. On the other hand, although epileptic 
vertigo often constitutes the only form of seizure from which patients 
suffer, attacks of a severer kind are in such cases always liable to su- 
pervene. 

The circumstances which determine the epileptic fit in those who are 



EPILEPSY. 



999 



liable to fits are not generally discoverable. They often, at all events 
when they first appear, come on only in the night, either, it is said, at 
the moment of going to sleep, or at the moment of waking ; and, even 
when they take place both day and night, they often occur mainly at 
night-time. It is not uncommon for them to come on in women at 
the monthly periods; yet it still more frequently happens that epileptic 
j women do not suffer specially at the time of menstruation ; and they 
I escape as a rule during parturition, a time at which eclampsia has a 
| special tendency to supervene. In some cases the fit seems to be in- 
! duced by severe mental labor, by emotion, by a debauch. It has not 
unfrequently occurred during the act of coitus. Sometimes, when the 
attack is preceded by an aura starting from some accessible point, the fit 
may be induced by the irritation of that point. Thus we have known 
it in one case to be invariably induced by compression of a certain ten- 
der spot in the abdominal walls; and we have met with another case 
in which for many weeks fits were brought on day and night whenever 
| the patient's legs were moved voluntarily or involuntarily, whether he 
was awake or asleep. 

The condition of epileptic patients in the intervals between their 
seizures is very various. In a large proportion of cases they appear to 
be in the enjoyment of perfect mental and bodily health. Not unfre- 
quently, however, some peculiarities reveal themselves sooner or later 
in connection with their nervous organism. Thus they become more 
or less low-spirited or taciturn, or querulous, fidgety, or excitable; or 
there may be a little failure of memory, or some slowness of apprehen- 
sion, or difficulty of application. The most remarkable mental phe- 
nomena, however, are those which are included in the term " epileptic 
mania." The attacks of mania resemble those which have been already 
referred to as constituting a portion of the epileptic paroxysm; but 
they may occur independently of the epileptic fit, and may last from 
a few hours or two or three days, to a week or two or more. They are 
remarkable, as a rule, for the suddenness of their invasion and the sud- 
denness of their subsidence. They present two varieties which by Dr. 
Falret are termed respectively petit mat and haut mat The latter is 
furious, attended with sudden attacks of uncontrollable violence and 
ideas and hallucinations of a terrifying character; the language of the 
patient is less incoherent than that of many other lunatics, and it is 
remarkable that each successive maniacal attack repeats the main fea- 
tures, in almost every detail, of the attacks that have gone before. In 
i the petit mal the patient is morose and despondent, and mistrusts and 
! fears those who are about him; he is impelled, as it were, by some 
superior power, in obedience to which he performs acts that he would 
not otherwise do ; he leaves his home and occupation, wanders about, 
and is liable to sudden outbreaks of passion, in which he will attack, 
destroy, or kill whatever comes in his way, or commit suicide. In 
both forms of mania the comparative coherence of the patient might 
lead one to suspect that he was either malingering, or under the domi- 
nance of simple revenge or passion. Yet his memory of what has 
occurred in his attacks is exceedingly defective ; sometimes he recol- 
lects nothing ; more often he recollects fragments of what has happened, 



1000 



DISEASES OF THE NERVOUS SYSTEM. 



as of a dream ; but he can rarely call to mind all that has taken place, 
and perhaps forgets the main incidents entirely. In some cases the 
patient's mind undergoes gradual deterioration, and he becomes im- 
becile or idiotic. It is said to be principally in the case of the petit 
mal that this result ensues. [This is probably due to the fact that the 
seizures are usually of much more frequent occurrence in the petit mal 
than in the haut mal; the number of times the fits are repeated appar- 
ently having more influence in the production of impairment of the 
mental powers than their severity.] In reference to this point, how- 
ever, it must not be forgotten that epileptic fits are apt to supervene in 
cases of chronic madness, idiotcy, and dementia. 

Epilepsy does not tend immediately to shorten the duration of life ; 
nevertheless it materially increases the risks to life. Thus the epileptic 
patient is liable to incur serious accidents : to fall into the fire and be 
burnt, to tumble into the water, to be drowned while bathing, or to 
fall from his horse, or from a scaffolding, or over a precipice; he may 
also be choked when eating, or asphyxiated as he lies in bed. Very 
rarely the fit itself proves fatal without extraneous aid ; when it does, 
the patient dies from asphyxia during its first stage, or from exhaustion 
or coma during the continuance of the status epilepticus. 

From the multiform characters which epilepsy presents, its diagnosis 
is often a matter of extreme difficulty. When occurring only at night- 
time, it not unfrequently happens that the patient is ignorant of the 
nature of his malady or even that he has anything the matter with 
him. Yet, even in cases of this kind, a hint, or an admission, or the 
statement of some special occurrence may awaken the suspicions of the 
medical man. Thus the patient wakes up uneasy, with giddiness or 
headache, or confusion of mind, from which he slowly recovers ; or he 
finds that his tongue is sore, and that there is blood upon his pillow ; 
or he notices petechial spots upon his face, neck, and chest; or he finds 
that he has passed his evacuations into the bed, or that he has dislo- 
cated his shoulder, or otherwise injured himself. Now any of these 
accidents may occur independently of epilepsy ; but if they recur from 
time to time, and especially if two or three be associated, the evidence 
in favor of epilepsy becomes very strong. 

The actual epileptic attack may be confounded with apoplexy or 
with hysteria. The true apoplectic attack — the attack in which the 
patient falls down suddenly comatose — is now generally allowed to be 
epileptic or epileptiform. The point, therefore, to determine in such 
cases is not whether it be apoplectic or epileptic, but what is the patho- 
logical condition on which the loss of consciousness depends. For the 
consideration of this point we must refer the reader to the article on 
apoplexy. The distinctions between the hysterical and the epileptic 
fit are generally well-marked, and little doubt usually remains when 
the history of the case is obtained. Still the affections appear to run 
into one another, and the condition termed hysterical epilepsy forms 
the link between them. The main points to bear in mind in forming 
a diagnosis are (apart from the patient's history) the usually much 
greater violence and much longer continuance of the paroxysm of hys- 
teria, the more general distribution of the convulsive movements, and 



EPILEPSY. 



1001 



the generally great and persistent noisiness of the patient. The hys- 
terical patient, moreover, is seldom .unconscious, can generally be 
roused without much difficulty, rarely bites her tongue, passes her 
evacuations into the bed, or injures herself; the skin, too, is hot, and 
the pupils act under the influence of light. 

Few diseases are so frequently feigned as epilepsy. The coarser 
i features of the haut mal are so striking that few persons can fail, with 
I a little study, to imitate them fairly well. There are various points, 
however, about the real attack which the actor does not observe, or 
! cannot copy. Thus he neither bites his tongue, nor passes his evacua- 
| tions into his trousers ; his pupils are probably not dilated, and cer- 
tainly not insensible to light; and his skin becomes hot and perspiring 
with his violent muscular exertions. Further, when he falls he takes 
care not to hurt himself; he overacts the convulsive part of the attack, 
but probably fails in details; moreover, he is alive to what is going on 
around him, takes furtive glances at the bystanders, and gives distinct 
; evidence that he feels if he be hurt, or if a jugful of cold water be 
thrown over him. Still there may be real difficulty ; and it behooves 
the physician not to commit the error of assuming that a real epileptic 
is malingering. The stage which succeeds the period of insensibility 
i is one not likely to be copied by a cheat ; yet it is a stage in which it 
j is often not difficult to persuade oneself that the patient is shamming. 
Morbid Anatomy and Pathology. — There are few diseases about the 
pathology of which we are so entirely ignorant as we are about that of 
epilepsy. It has been referred to anaemia of the nervous centres ; it has 
been referred to hyperemia; it has been assumed that the convolutions 
of the hemispheres, the ganglia at the base, or the pons and medulla 
oblongata are mainly at fault ; and the disease has been regarded as one 
involving the nervous centres as a whole. Morbid anatomy scarcely 
helps us, for in the rare cases in which death has occurred in a fit, little 
or nothing more than hyperemia has been detected, with in some cases 
haemorrhage into the perivascular sheaths of the smaller vessels ; and 
when chronic epileptics have been examined post mortem, either the 
brain has looked healthy, or it has appeared to have shrunk somewhat, 
or there has been some induration of the white matter, or some thick- 
ening of the walls of the minute vessels, with traces of previous haemor- 
rhage in their vicinity. It must be added, however, that these lesions 
have been mainly recognized in the brains of those whose epilepsy was 
associated with chronic insanity or dementia. Experiment has clearly 
shown that anaemia of the brain, suddenly produced, causes epileptiform 
! convulsions ; but, on the other hand, extreme congestion of the brain as 
I occurs during the prolonged paroxysmal cough of pertussis is also fol- 
lowed by insensibility, associated with convulsive twitchings. There 
is every reason on clinical grounds to believe that in the epileptic par- 
oxysm the brain is successively anaemic and congested. The extreme 
pallor which overspreads the surface at the commencement of the 
attack, and which has been observed, we believe, by Dr. Jackson to 
! pervade the retinal vessels as well, may be taken as a clear indication 
that the brain itself is also anaemic at that time. And the great venous 
and capillary congestion which almost immediately afterwards replaces 

I 



1002 



DISEASES OF THE NERVOUS SYSTEM. 



that pallor, coupled with the presence of post-mortem congestion and 
capillary haemorrhages in the brain in fatal cases of epilepsy, show 
clearly that the early anaemic condition of the brain is soon succeeded 
by notable congestion. But, even if it be allowed that anaemia of the 
brain is the cause of the earliest epileptic phenomena, including the 
tonic spasms, it is obvious that it is not the cause of the clonic spasms 
which come on with the congestion. Dr. Marshall Hall, who clearly 
recognized this sequence, referred the clonic spasms to the congestion 
which followed upon the cessation of the respiratory acts, and recom- 
mended the performance of tracheotomy with the object of preventing 
their supervention, and so of robbing the disease of its chief horrors. 
It must be added that if the epileptic phenomena depend on mere con- 
gestion or anaemia, this must obviously originate in some functional 
disturbances at the source of the vaso-motor nerves which are distrib- 
uted to the cerebral vessels. 

The medulla oblongata and upper part of the cord are regarded by 
Dr. Reynolds as the primary seat of epilepsy. And MM. Luys and 
Voisin, as the result of very careful post-mortem investigations, con- 
clude that the parts which mainly surfer in this affection are the medulla 
oblongata, the corpora striata, the cerebellum, and other parts at the 
base of the brain. On the other hand, it has been shown by Brown- 
Sequard that epileptic convulsions may be artificially induced in guinea- 
pigs as a consequence of section of one of the lateral columns of the 
cord anywhere between the medulla and the tenth dorsal vertebra. It 
must be admitted, indeed, that both tonic and clonic convulsions may 
be of spinal origin, and that in epileptic convulsions the motor tract of 
the cord must necessarily be largely concerned ; at the same time, from 
the special implication of the nerves at the base of the brain, there can 
be no cloubt that the motor nuclei in the medulla oblongata and on the 
floor of the fourth ventricle and iter must at least be equally affected ; 
further, from the generally unilateral tendency of the spasms or from 
the predominant action of the muscles of one side when both sides are 
involved, there is great reason to suspect that, however much the various 
nuclei of the motor tract are involved, they are dominated by the supreme 
centre of motion, namely, the corpus striatum. Still, when we look to 
the clinical facts of epilepsy, and recollect that convulsion is by no 
means the most frequent or the most important element of the epileptic 
attack, that when it occurs it is usually preceded by some aura, some 
sensation, some spasm, some hallucination, and is attended from the 
beginning either with total loss of consciousness or with a dreamy con- 
dition in which there is often a total insensibility to external impres- 
sions, it is impossible not to acknowledge that, however seriously the 
cord, medulla, and ganglia at the base of the brain may be implicated 
subsequently, the earliest phenomenon must be connected with some 
limited spot of the nervous centres, which, though different for different 
cases, is probably always the same for the same case ; that the pain, or 
the sensation, or the giddiness or the hallucination, is probably of cen- 
tral origin ; and that from this primarily affected spot a sudden influ- 
ence is discharged over the sensorium and the sensori-motor regions of 
the cerebrum, which as regards the sensorium either annuls conscious- I 



EPILEPSY. 



1003 



ness wholly or in part, or perverts it; and as regards the motorial 
system, either excites it to unwonted or perverted action, or arrests its 
operations. There is reason, therefore, to believe that the epileptic fit 
commences before the brain becomes anaemic, and room, therefore, to 
question whether this anaemic state of the brain is the cause or the 

i consequence of the symptoms which accompany it. There is equal 

| reason to doubt, we think, whether the congestion which follows the 

• anaemia is the cause of the clonic contractions and of the various 
phenomena which attend their occurrence; and whether, finally, the 

' after-symptoms are to be referred (as some suppose) to carbonic acid 

] poisoning. The pathology of the affection is, we repeat, obscure, and 
we do not attempt to elucidate it. 

Treatment. — During the epileptic attack there is usually little to be 
done beyond preventing the patient from injuring himself, and remov- 
ing all sources of pressure from his neck. It may sometimes be well 
to prevent him from biting his tongue by inserting a pad between his 

I teeth. Convulsions may often be allayed by the inhalation of chloro- 
form ; and sometimes it may be advisable, when the congestion of the 
face is extreme and long-continued, to remove blood from the distended 
vessels of the neck. Not un frequently, when the attack is preceded by 

i a warning of sufficient duration, it may by proper management be 
averted. Among measures which have been successfully adopted for 
this purpose are: the inhalation of chloroform or ammonia, the admin- 
istration of a dose of sal volatile or ether, the application of a ligature 
above the point from which an aura springs, or the forcible prevention 
of the closing of the fingers or the flexion of the arm, when such move- 
ments constitute the premonitory symptoms. Latterly Dr. Crichton 
Brown has, for the same purpose, had recourse with success to the 
inhalation of nitrite of amyl. 

The measures which have been employed to cure epilepsy are innu- 
merable. Many drugs have been administered with more or less success, 
among which may be enumerated the sulphate and the oxide of zinc, 
arsenic, copper, iron, nitrate and oxide of silver, and bromide of potas- 
sium; belladonna, digitalis, strychnia, opium, and Indian hemp; as 
also musk, valerian, and assafcetida. The list might easily be extended. 
Of the above, those which have perhaps enjoyed the widest reputation 
are the salts of zinc, silver and arsenic, belladonna, and the bromides of 

' potassium and ammonium. Belladonna has been strongly advocated 
by Trousseau, who recommends that it be given in the form of a pill 
containing \ grain severally of the extract and powdered leaves, or that 

i in its place the T io tn °f a g ram °f the sulphate of atropia be administered. 

j He recommends that during the first month one of the pills be given 

i daily, and that a pill per month be added, until the daily allowance of 
pills amounts to from five to twenty. He strongly urges that the pills 
be given either night or morning, according as the fits are nocturnal or 

| by day, and invariably at the same hour in the same case. Bromide of 
potassium has been the favorite remedy of late years, and there is no 

! doubt that its use is often highly beneficial and sometimes curative. 

j The dose should vary from 10 to 30 grains three times a day, and it 
should be given for a considerable length of time. But probably more 



1004 



DISEASES OF THE NERVOUS SYSTEM. 



important than medicine is careful attention to hygiene ; the patient's 
habits should be ascertained, and if in fault, corrected; masturbation 
and excessive venereal indulgence should be checked; over-eating, and 
especially over-drinking, late and irregular hours, and excitement of 
all sorts should be avoided. He should live quietly, keep good hours, 
take nourishing wholesome food, eschew alcohol as far as possible, 
attend to the condition of his evacuations, and, if need be, have change 
of air and scene. It is often a question whether the patient should 
give up work, whether if a man he should cease to engage in his ordi- 
nary business pursuits, if a child, give up learning. The answer to 
such questions must depend on the special circumstances of the case. 
No doubt when the fits are severe and frequent, it may be well to cease 
at least for awhile from all mental labor and sense of responsibility; 
but in the great majority of cases there is every reason to believe that a 
certain amount of mental occupation, and it may be added of bodily 
exercise, is beneficial to the patient, and that, on the other hand, entire 
cessation from work is injurious. As a rule, therefore, the child should 
pursue his studies, the adult his usual avocations; but neither should 
he be allowed to push his work to excess. Lastly, counter-irritation, 
setons and issues behind the neck, shower-baths, cold-baths, and ice 
along the spine, and even the removal of the clitoris or of the testicles 
have each had their special advocates. There are no sufficient grounds, 
however, for believing any one of these measures to be really beneficial. 

Eclampsia. 

Definition and Causation. — This is the name which is now commonly 
applied to all those varieties of epileptiform convulsions which occur 
accidentally, so to speak, in dependence on some specific lesion or the 
presence of some special pathological or physiological process. Eclamp- 
sia may be one of the phenomena consequent on fracture of the skull, 
effusion of blood into the brain, or on the obstruction of a cerebral 
artery ; it may be developed in connection with the growth of an intra- 
cranial tumor, whether this be tubercular, syphilitic, carcinomatous, 
hydatid, aneurismal, or other; it is liable to occur when there has been 
sudden and copious loss of blood, when the brain is deeply congested, 
or when certain poisons circulate in the blood — it thus attends poison- 
ing by hydrocyanic acid or absinthe, the retention of effete matters in 
the blood from renal disease, and in young children is often one of the 
earliest indications of the operation of the scarlatinal poison, or that of 
other infectious disorders ; further, it is often induced by reflex action, 
and thus in some cases occurs during parturition, and in children is 
often a consequence of the irritation of teething, of gastro-intestinal 
disturbance, and of many slight local conditions which in older persons 
would be followed by little or no inconvenience. 

Symptoms and Progress. — The fits of eclampsia are not distinguish- 
able from those of true epilepsy; they may be exceedingly slight, they 
may be robbed, as it were, of one or more of the recognized stages, or 
they may present in a typical form all the sequence of events charac- 
teristic of the haut mcd. It may be well, however, to recollect that 



ECLAMPSIA 



— INFANTILE CONVULSIONS. 



1005 



they are often less sudden in their invasion ; that the patients are less 
liable to lose consciousness absolutely than true epileptics are; that the 
fits much more frequently have a fatal issue, resulting either from coma 
or from exhaustion; and that they are much more irregular in their 
occurrence, probably, however, becoming more and more frequent and 
severe if the affection on which they depend is a progressive one, or 
ceasing permanently if the cause of their occurrence is removed. 
Further, with the exception that children who have eclampsia some- 
times become epileptic in after life, these accidental fits seldom or never 
merge into true epilepsy. The diagnosis of these cases must depend 
less on the phenomena of the attack than on their history and the cir- 
cumstances which attend them, such as the presence of constitutional 
syphilis, the existence of renal disease, the fact that symptoms of cere- 
bral disorder have been gradually creeping on before the convulsions 
attacked the patient, the evidences of abundant loss of blood, the prog- 
ress of parturition, and the like. 

• Treatment. — The treatment of eclampsia will depend mainly on the 
diagnosis at which we arrive; thus syphilitic eclampsia will need to be 
treated with iodide of potassium and mercury ; renal eclampsia will 
probably demand the use of powerful drastic purgatives ; aneemic 
eclampsia will call for good nourishment and stimulants ; eclampsia 
arising from accidental causes of irritation will require the removal of 
these causes ; while that variety which is connected with progressive 
cerebral disease can only be treated by palliative measures. 

Infantile Convulsions. 

Definition and Causation. — These are rarely epileptic in the true sense 
of that term, and come therefore properly under the head of eclampsia. 
There are reasons, however, for giving a separate brief consideration 
to them. 

Convulsions arise in young children, especially during the time of 
teething, with remarkable readiness and frequency; and indeed Dr. 
West remarks that convulsions in children seem often to take the place 
of delirium, as they do also of rigors, in adults. It is certain that they 
are very often indeed developed in the course of diarrhoea and various 
other disorders of the gastro-intestinal tract ; that they occur in bron- 
chitis and other affections of the respiratory apparatus ; that they come 
on not only at the period of invasion of scarlet fever and other like 
diseases, but that they may be induced in the course of these disorders 
by various accidental circumstances ; that they often depend on mere 
innutrition or ansemia; that they are common in the case of rickety 
children ; and that they are peculiarly liable to occur in connection 
with the irritation of teething. It need scarcely be added that children 
are liable as adults are to convulsions in the course of the development 
of tumors, or of other diseases of the brain or its meninges. 

Symptoms and Progress. — The convulsive attacks of children do not 
differ essentially from those of adults. They may be equally numerous, 
equally violent, and the " status epilepticus " may equally be developed. 
They vary also in their intensity between the widest extremes. They 



1006 



DISEASES OF THE NERVOUS SYSTEM. 



do not, therefore need any special description. Slight fits, or threaten- 
in gs of fits are very often indicated, either when the child is awake or 
when he is asleep, by sudden spasm of one or both hands with turning 
inwards of the thumb upon the palm ; by a momentary fixedness in the 
child's look, attended' probably with pallor, dilatation of pupils, squint- 
ing:, or some convulsive twitches of the face or limbs. It not unfre- 
quently happens in children that the incidents of the fit are mainly 
connected with spasmodic contraction of the glottis and of the respira- 
tory muscles. Respiration suddenly ceases, the face becomes livid and 
bloated, the veins swell, there is some rolling of the eyes, some con- 
vulsive movements of the muscles of the face; then the head falls 
upon the chest, and the limbs become flaccid, the pulse gets feeble, 
quick, and perhaps imperceptible, bloody sputum issues from the mouth, 
copious perspirations break out, and if respiration be not speedily re- 
stored death ensues. In some instances such attacks are ushered in 
with a kind of crowing inspiration (laryngismus stridulus); in many 
they are perfectly silent. They are sometimes brought on during the 
continuous holding of the breath, or continuous expiration, which occurs 
when the child begins to cry, or when he is coughing or about to cough, 
and especially in connection with the paroxsymal attacks of hooping- 
cough. The number of fits which children suffer from and the fre- 
quency of their recurrence vary very greatly. Sometimes the child 
has a single fit, and never any more ; sometimes the fits recur many 
times a day, and the child may experience many hundreds of them in 
the course of a year. Not unfrequently, as before stated, he may pass 
into the status epilepticus and remain in that condition for some hours 
or even a day or two. Infantile convulsions are always, and on good 
grounds, a matter for serious alarm ; it is astonishing, however, how 
children will suffer from almost innumerable fits occurring off and on 
for months and years, and yet recover perfectly. On the other hand, 
they are often fatal. The most dangerous are those which chiefly im- 
plicate the respiratory organs and those which by their rapid succession 
render the child comatose for a long period. The immediate cause of 
death is either suddenly or slowly induced asphyxia, or asthenia. Fits 
often repeated have in some instances similar results to those occurring 
in adults ; they are sometimes followed by more or less permanent hemi- 
plegia or some other form of paralysis, and by failure of intelligence 
or by idiotcy. Stammering, squinting, and other such defects are 
sometimes attributed to the occurrence of fits in early life. 

Treatment. — The principles of treatment are the same for infantile 
convulsions as for those occurring in adults. Tljie child's general health 
must be carefully maintained or improved ; all affections, all causes of 
irritation, which are present must be removed. Bronchitis must be 
cured, diarrhoea checked, irritability of the stomach assuaged; if the 
gums are congested and swollen, and the child is evidently suffering in 
consequence, they should be freely lanced, and the operation should be 
repeated whenever the indications of irritation return ; if the child has 
been having unwholesome or insufficient food, or if he has been overfed, 
these conditions must be obviated. The various specific modes of treat- 
ment are as applicable in the case of young children as in that of adults; 



HYSTERIA. 



1007 



and hence belladonna, bromide of potassium, antispasmodics, and other 
remedies have all been recommended, and in certain cases have been 
found serviceable. In the fit itself, there seems no reason to object to 
the ordinary practice of putting the child into a hot bath, and applying 
cold water or a sponge dipped in cold water to his head or face. Chloro- 
form inhalations may also be had recourse to. Fits may sometimes be 
averted by applying ammonia to the nose, or cold water to the face, at 
the moment of their commencement, or when premonitory symptoms 
are heralding their approach. 



HYSTERIA. 

Definition. — It is difficult to describe, still more difficult to define, 
hysteria. It may, however, in general terms, be said to be a functional 
disorder of the nervous system, occurring mainly in females from the 
age of puberty upwards, in which the will, the intellect, the emotions, 
sensation, motion, and the various functions which are under the influ- 
ence of the nervous system, are involved, or apt to be involved, in a 
greater or less degree. 

Causation. — As has already been stated in the definition of the dis- 
ease, hysteria affects females principally, and usually makes its appear- 
ance in them for the first time between the age of commencing puberty 
and that of five-and-twenty. It may- come on, however, previous to 
puberty, and at any age after twenty-five; but in the latter case more 
especially about the time of the cessation of the menses. Males occa- 
sionally become distinctly hysterical; but there does not appear to be 
the same tendency in them as in women for the disease to come on in 
early life. The causes of hysteria, like those of so many other func- 
tional nervous disorders, are very obscure. There are two or three, 
however, which seem to have a very important influence, direct or 
indirect, in its causation; these are emotional disturbance, sexual con- 
ditions, and occupation. 

Nothing is more certain than that hysterical phenomena and the 
hysterical fit itself are frequently induced by circumstances which affect 
the emotions powerfully, such as sudden fright or horror, powerful 
religious impressions, disappointed love or hope deferred, grief, jealousy, 
and the like. And indeed in those who are strongly predisposed to the 
affection the most trivial disturbances of this kind are liable to provoke 
violent outbreaks. It must be added that hysteria, like chorea and 
epilepsy, is often contagious. 

The name hysteria was given to the disease under consideration in 
the belief that the womb was its seat. The fact that it occurs amongst 
men shows that that view of its origin cannot, at least in all cases, be 
correct. As regards females, however, there can be no doubt that the 
reproductive functions or organs do exercise a greater or less influence 
over its production. It comes on usually about the period of puberty 
or that of the climacteric change. Though not by any means occurring 
only in unmarried women, and those who are unhappily married, it 



1008 



DISEASES OF THE NERVOUS SYSTEM. 



occurs in them much more frequently than in such as become the happy 
mothers of families. And again, in no inconsiderable number of cases 
there is distinct evidence of involvement of one or both ovaries in the 
facts that they are painful to pressure and that characteristic hysterical 
symptoms may be induced by applying strong pressure to them. There 
is, however, no necessary connection between the condition of the cata- 
menial flow and hysteria, although it must be admitted that the cata- 
menia are often at fault in hysterical women, and that occasionally 
their restoration to the normal condition is attended with the restora- 
tion of the patient's general health. Nor is there sufficient ground for 
believing that the mere default of sexual congress either in the male or 
female has, as a rule, any important influence in its causation ; except- 
ing perhaps in so far as it may be connected with the yearning for love, 
the sense of neglect, jealousy, and other such feelings. Sexual excesses, 
and especially masturbation, have been assigned as causes. 

There can be little doubt that occupation and position in life have 
something to do with the production of hysteria ; for it is a disease 
which affects the higher classes in a disproportionate degree ; but if 
these conditions are concerned in its causation, it is owing to the acci- 
dental fact that wealth brings with it the Heedlessness for work and the 
capability of indulgence in frivolous amusements and idleness, with 
consequent neglect of the healthy exercise and discipline of the mind. 
Other causes which have been assigned for hysteria are : hereditary 
predisposition, overwork, anaemia, debility, and other forms of failure 
of health ; but any influence they may exert is at best very remote. 

Symptoms and Progress. — In describing the clinical phenomena of 
hysteria we will first discuss the mental characteristics of those who 
suffer from it, and then consider seriatim the various motor, sensory, 
and sympathetic disturbances which are apt to be associated with them. 

The mental conditions of hysterical patients present the greatest 
variety, and yet there are gradations between the extreme conditions 
which prove their relationship. In many cases women who are liable 
to hysterical attacks under occasional states of ill-health or excitement 
are in the intervals between their attacks as healthy in body and in 
mind, and as free from all caprice or peculiarities of temper, as we could 
wish to see them. They will, however, often acknowledge that at the 
moment when hysterical feelings come upon them, they feel compelled 
to yield to them, and indisposed to make any effort to restrain them ; 
and that yet if anything occurs to incite them to use self-control, they 
are able to resist them successfully. In other cases the patient is ner- 
vous and excitable, with little control over either her emotions or her 
actions, apt to laugh or cry on the slightest provocation and incon- 
gruously, and apt also to suffer from time to time from the various 
complications of hysteria. But in a very large proportion of cases 
(either with or without the outward manifestations of hysteria which 
have been just enumerated) the whole moral character of the patient is 
more or less profoundly altered. She is apathetic and neglectful of her 
duties, or exacting, selfish, and suspicious, exaggerating all her trivial 
annoyances and discomforts or disorders, resenting all healthy advice 
or reasonable attempts to promote her welfare, and quarrelling there- 



HYSTERIA. 



1009 



fore it may be with her husband or dearest friend, but pouring out 
profuse affection on all those acquaintances, however new they may be, 
who affect to pity her condition, make the most of her ailments, and 
adapt themselves to all her changing moods and caprices. Under such 
circumstances it is astonishing to see women, well nourished, and 
apparently in the best of general bodily health, remain for months and 
years useless members of society, suffering from paralyses and other 
maladies which they profess to look upon with the utmost alarm (and 
which they declare perhaps to be family complaints) not only with 
quiet complacency, but with a studied resistance to all plans of treat- 
ment likely to be of service to them. They are probably only too 
willing, however, to put themselves into the hands of some fashionable 
charlatan, or to do anything else which will render their misfortunes 
in any degree notorious. It is but a step from hugging her ailments 
and exaggerating them to malingering. And although we cannot 
fairly accuse the great majority of hysterical patients of shamming, 
shamming is by no means uncommon. The craving for pity and 
notoriety increases by being fed; the greater the commiseration she 
excites, the more does the patient endeavor to be worthy of it, and the 
more serious become the ailments from which she is suffering ; and 
soon perhaps new phenomena become developed. It is an interesting 
and important fact that the nature of these phenomena is not unfre- 
quently determined by the direction which the interest and solicitude 
of the doctor or friends happen to take. If they pity her failing appe- 
tite, she soon, perhaps, affects to live without food ; if it be observed 
that her urine and motions are scanty, she finds before long that they 
cease altogether; if it be a matter of wonder or speculation what be- 
comes of her evacuations, she will be found, perhaps, to vomit urine or 
faeces, or blood. It is by such patients, though not by these alone, 
that various other forms, more or less singular, of malingering are 
practiced. Thus at one time a patient will bring on hard oedema or 
spurious elephantiasis of the arm or leg by the constant application of 
a ligature round the upper part of the thigh or arm, and will even 
submit to the amputation of the limb; at one time she will, by the 
constant application of some irritant substance, fret her skin into 
ulcers, and thus even cause perforation of the stomach ; at one time she 
will place lumps of coal up her vagina and pretend that she is suffer- 
ing from vesical calculus ; at one time she will affect to have com- 
| munion with the Virgin Mary, to have the marks of the stigmata on 
j her hands and feet and side, and at the same time, probably, to live 
i devoid of all those natural appetites and wants which are inherent in 
j mortality. It must be added that insanity occasionally supervenes. 

We will proceed now to describe the various phenomena which are 
! so apt to go along with the mental states which have just been con- 
| sidered, and which form, as a rule, the more striking phenomena of 
! hysteria. 

Convulsions. — These vary very much in their severity and duration, 
I and have a more or less general resemblance to those of epilepsy, from 
j which, however, it is important to distinguish them. The patient is 
; rarely attacked without warning. She has probably, for some little 

64 



1010 



DISEASES OF THE NERVOUS SYSTEM. 



time previously, been suffering from hysterical symptoms ; she has been 
laughing or crying or sobbing, or been talking wildly or gesticulating 
violently, or she has complained of a sense of constriction or of a ball 
in the throat, or she has manifested, in a marked way, some of the 
mental or emotional phenomena which are characteristic of hysteria. 
Then suddenly, perhaps, she utters a loud scream, and falls upon the 
sofa or the ground violently convulsed. The fit may last for a few 
moments, or be prolonged for a quarter of an hour, or may be contin- 
ued by successive attacks for many hours, interrupted from time to 
time by cries, and sobs, and laughter. Such phenomena generally also 
attend the subsidence of the attack ; or if the patient be worn out with 
her long-continued exertions, she falls into a sound sleep. The main 
points by which the hysterical fit may be distinguished from the epi- 
leptic are the following : The hysterical patient is very rarely, no 
matter how severe the attack may be, totally unconscious ; she can 
generally be roused either by the voice of authority, or a douche of 
cold water; she is much more noisy — the epileptic utters a single cry, 
or none at all, while the hysterical patient probably screams and cries 
and laughs and groans, or talks volubly and incoherently off and on 
during the whole of her attack ; her convulsions are much more gen- 
eral and extensive — she throws her arms and legs about in all direc- 
tions, she twists her body into the most grotesque attitudes, she 
suddenly raises herself to the sitting posture, and then throws herself 
violently down again, but with all this violence and excess of muscular 
effort, she rarely, if ever, injures herself; the convulsions are rarely 
tonic at any period of the attack ; they are rarely, if ever, unilateral, 
and the face (unless when the patient be crying out) is free from the 
hideous distortion of epilepsy ; she does not bite her tongue ; the eye- 
lids are closed and tremulous, but the pupils respond to light, and there 
is no tendency to squint ; her respiration never ceases, but is from the 
beginning noisy and irregular, and consequently, although the skin 
may become hot and perspiring, the patient never presents that lividity 
of countenance which attends the true epileptic attack ; she does not 
discharge the contents of her rectum and bladder ; and lastly, if we 
investigate the history of the patient, we never find that she presents 
attacks of the petit mal or epileptic vertigo. Yet though the distinc- 
tions between epilepsy and hysteria are for the most part easy, instances 
are sometimes met with in confirmed and severe cases, in which the 
hysterical attack puts on some of the features of epilepsy. It is then 
attended with sudden and total unconsciousness, and it may be with 
tonic spasm, temporary arrest of respiration, lividity of face, and biting 
of the tongue ; but even here the antecedent presence of the globus hys- 
tericus and other indications of hysteria, and the ultimate conversion of 
the attack into one of obvious hysteria are generally quite sufficient to 
render diagnosis easy. Charcot points out as a further distinction 
between these attacks and those of true epilepsy, that they never lead 
to impairment of the intelligence or dementia ; he further points out 
as an important distinction between the status epilepticus and the cor- 
responding condition in hysteria, that in the former case the tempera- 



HYSTERIA. 



1011 



ture rises to 103° or 104° or more, while in the case of hysteria it 
rarely exceeds the normal by more than one or two degrees. 

Hyperesthesia is exceedingly common among hysterical women. It 
may be general, or hemiplegic, or paraplegic, or it may affect a limb, 
or a joint, the mamma or the ovary, the spine, or indeed any part of 
the surface or any organ. Pain varies in its severity, is sometimes 
induced only by pressure, but often occurs quite independently of all 
external sources of irritation. It is a curious and suggestive, but not 
invariable, characteristic of it, that the patient will shrink from the 
slightest touch when she is expecting it, and yet will allow the painful 
part to be compressed and handled violently when her attention is 
directed to other matters. A common pain of which hysterical women 
complain is that which is termed clavus ; it is generally referred to the 
forehead just above the eyebrow, and is likened to the effect of a nail 
driven into the skull. The most interesting variety of hyperesthesia, 
however, is that of which the globus hystericus forms a part. The 
globus hystericus is a sensation as of a ball rising into the throat and 
impeding respiration j it is of frequent occurrence in hysterical patients, 
and is commonly present before and during paroxysmal attacks. It 
often seems to arise from the iliac fossa. The patient then complains 
of pain or tenderness on pressure in this situation, whence from time 
to time the hysterical aura, as it may be termed, seems to spread, first 
to the epigastrium, sometimes causing nausea and vomiting; then to 
the chest, provoking violent action of the heart and palpitation ; then 
to the neck, constituting the globus hystericus, which is often asso- 
ciated with sobbing, choking, and other such symptoms; and thence 
finally, according to M. Charcot, to the head, when it induces noises in 
the ears, dimness of vision, and clavus, all on that side of the body 
from which the aura started. These phenomena constantly precede the 
occurrence of the hysterical fit, and according to the older writers, with 
whom M. Charcot is completely in accord on this point, are referable 
to some peculiar condition of one or other ovary, generally the left. 
He states that in a large number of hysterical women there is a tender 
point which may be discovered on deep pressure made directly back- 
wards at the point of intersection of the horizontal line drawn between 
the two antero-superior spines of the ilia, and the continuation down- 
wards of the vertical line which marks the lateral boundary of the 
epigastrium ; that this point represents the ovary, which may, in fact, 
w T hen the abdominal walls are flaccid, be often distinctly felt in this 
situation ; and that continued pressure upon it will induce all the phe- 
nomena above described of the hysterical aura. This iliac or hypo- 
gastric pain varies in its severity ; in many cases it can only be dis- 
i covered by hunting for it ; but in many extreme pain and tenderness, 
; so great as to forbid the slightest pressure, occupy not only the ovary 
but the superposed muscles and skin ; and occasionally these phe- 
| nomena become so widely diffused as to simulate the local symptoms of 
peritonitis. Hyperesthesia of the organs of special sense — intolerance 
of light, intolerance of sound, and intolerance of certain sapid or odor- 
ous substances, often associated with extreme acuteness of these senses-*- 
is very common in hysterical women. But here again the phenomena 



1012 



DISEASES OF THE NERVOUS SYSTEM. 



generally present that marked characteristic of hysteria, namely, that 
the patient will complain bitterly of the slightest impression when her 
mind is directed towards it, but will endure the most discordant sound 
or the brightest light when her attention is distracted by other objects. 

Anaesthesia, again, is of frequent occurrence among hysterical per- 
sons. It may occur in various parts of the body, and be limited to the 
distribution of a single nerve ; it may affect the sense of smell, or taste, 
or may implicate the eye, causing dimness of vision or difficulty in 
recognizing colors. The most remarkable cases, however, are those of 
hemianesthesia, with or without coexisting loss of motor power. In 
this variety the loss of sensation as a rule involves uniformly the whole 
of one side of the body — leg, trunk, arm, and head and neck — ceasing 
abruptly at the median line; and it involves not merely the skin, but 
the mucous membrane of the mouth and the organs of sense, so that 
taste and smell are lost upon the affected side, and the eyesight fails. 
Further, it usually implicates the deeper-seated tissues as well, namely, 
the muscles, bones, and joints. It may be complete and profound, or 
it may be merely insensibility to pain, with or without insensibility to 
variations of temperature. The anaesthetic parts are usually pale, and 
their temperature more or less considerably reduced. In reference to 
diagnosis, it may be observed that complete hemianesthesia is exceed- 
ingly rare as a consequence of cerebral disease, and that in this case the 
affected limbs are usually hotter than those of the opposite side, and 
anaesthesia of the nerves of special sense rarely coexists with that of the 
nerves of ordinary sensation. 

Convulsive Movements. — These, which have already been sufficiently 
described in connection with the paroxysmal attacks of hysteria, con- 
sist mainly in violent clonic movements of the voluntary muscles of 
the limbs and trunk, and in spasmodic affection of the respiratory 
muscles, connected with sobbing, laughing, crying, and hiccough. 

Paralytic conditions are probably the most common of the compli- 
cations of hysteria. Like anaesthesia, paralysis may affect any part; 
it may involve the hand, the forearm, the entire upper extremity ; it 
may affect the leg or some part of it ; in some cases it assumes the 
form of paraplegia, in some that of hemiplegia ; or it may be irregu- 
larly distributed, or general. It seems very rarely to implicate the 
muscles of expression. The paralysis may be complete or incomplete. 
The affected limb or limbs may be flaccid or rigid. Electric contrac- 
tility remains for the most part unimpaired, but the electric sensibility 
of the muscles is more or less completely lost. The muscles do not 
waste. In the majority of cases hysterical paralysis may be distin- 
guished from other forms of paralysis with tolerable readiness, but not 
always. 

If the paralysis be hemiplegic, it comes on probably after an hys- 
terical fit ; it involves the arm and leg, but neither the tongue nor the 
face ; the affected limbs are probably rigid, the arm bent, the hand 
firmly closed, while the lower extremity, on the other hand, is extended, 
the toes pointed, and the limb and pelvis movable only in mass ; it 
may be that the arm is flaccid while the leg is contracted, or conversely ; 
the paralysis is probably associated with hemianaesthesia. [The gait 



HYSTERIA. 



1013 



of the hysterica] patient is so peculiar, that an experienced physician 
will rarely be misled by it into thinking that the apparent loss of 
power is really due to organic disease. Upon closely watching her 
movements it will be observed that she always drags her foot and 
makes no effort to use it. The true paralytic, on the other hand, while 
I she supports herself on the sound limb uses the muscles of the hip of 
j the other side — which usually regain power sooner than those lower 
| down — and by their aid swings the foot round to 'a position in front of 
j the other, thus causing it to describe a semicircle.] Now, it may be 
i remarked that the hemiplegia of organic brain disease is rarely asso- 
, ciated with complete hemianesthesia ; that it is never attended with 
persistent rigidity from the beginning, and that if in this case there be 
j any difference between the arm and leg in this respect, it is the arm 
! and not the leg which becomes rigid. If the paralysis be paraplegic, 
! the limbs are usually rigid and in a condition of extension ; and the 
paralysis with rigidity is probably, as in the other case, suddenly de- 
j veloped. 

Whether the paralysis be hemiplegic or paraplegic, or limited to a 
limb or the portion of a limb, it is apt to come and go, and to shift from 
limb to limb, or to involve more or less suddenly other limbs besides 
those first affected; and, above all, it is generally associated with other 
phenomena indicative of the presence of hysteria. It is important, 
however, to recollect that, although hysterical paralysis generally pre- 
sents variations in degree, in character, and in site, it is (especially in 

I its hemiplegic or paraplegic form) liable to continue for years or for 
life. And it is probable that, although as a rule the muscles remain 
unaffected as regards their bulk and contractility, they may, in cases 
of long standing, undergo degenerative changes from disuse, and that 
chronic lesions may also take place in the cord. 

Affections of the Larynx and Air-passages. — Aphonia is very com- 
mon ; the patient loses her voice completely and speaks only in the 
feeblest whisper ; she probably, however, has no soreness in the throat, 
no difficulty or pain in swallowing, no evidence whatever of local dis- 
ease. The voice, moreover, is generally feeblest when the patient is 
asked to display her powers ; and sometimes reappears with sudden 
force under the influence of momentary excitement or it may be of for- 
getful ness. In some cases there is actual dyspnoea, which becomes so 
extreme as to demand operative procedure. Not unfrequently a pe- 
culiar cough, which Sir Thomas Watson describes as " loud, harsh, 
dry, more like a bark, or a hoarse bleat, than a cough," is one of the 
special developments of hysteria ; it is apt to come on in paroxysms, 

; which may continue for hours without cessation, and may come on 
daily or nightly for weeks or months. In some cases, without ap- 

| parent cause, and with a pulse but little elevated above the normal, 

j the respirations will suddenly rise to 40, 50, or even 70 or 80 in the 
minute, and continue thus for some minutes, or on and off for some 

| hours, and yet without other evidence of dyspnoea or distress. 

Affections of the Alimentary Canal. — In some instances patients 
suffer from well-marked trismus, which interferes seriously with both 
speaking and eating ; occasionally they complain of difficulty of deglu- 



1014 



DISEASES OF THE NERVOUS SYSTEM. 



tition ; and distension of the stomach, with rumbling and eructations, 
is of common occurrence. Hysterical patients often suffer from vomit- 
ing, and in some cases this constitutes the most serious part of their 
malady ; the vomiting is apt to come on after every meal, or it may be 
at some particular time of the day, and to be continued day after day 
for months or years. This sickness is frequently associated with good 
or even voracious appetite ; but the bulk of matters vomited often 
seems in excess of the ingesta, and after a time extreme emaciation and 
debility probably ensue. The bowels are usually constipated, and there 
may be more or less pain in defecation. 

Affections of the Urinary Organs. — Retention of urine often occurs ; 
doubtless it sometimes depends on paralysis of the bladder, or con- 
traction of the sphincter, or pain in the act of micturition; but not un- 
frequently, like other hysterical conditions, it is more or less within 
the control of the patient, who makes no attempt to relieve herself 
voluntarily so long as she can enjoy the morbid pleasure of having the 
catheter passed for her. But more interesting than these are the 
phenomena connected with the secretion of urine. It usually happens, 
after an hysterical fit, or after other paroxysmal nervous disorders, that 
the patient passes large quantities of pale limpid urine. And such 
profuse discharge of urine is not unfrequent at other times. But it is 
also not uncommon to find the opposite condition present. The patient 
consecutively for many days does not pass more than a few ounces of 
urine; and in a remarkable case published by M. Charcot, the sufferer, 
a woman, forty years old, for more than a couple of weeks passed every 
other day only five grammes of urine, and none on the intervening 
days, and for a continuous period of ten days secreted no urine what- 
ever. During one month her average daily yield of urine was only 
three grammes, and during another month only two grammes and a 
half. In this case the diminution and suppression of urine were un- 
connected with renal disease, but were associated with constant vomit- 
ing, the quantity of fluid vomited having some supplementary relation 
to the quantity of urine voided. Further, the vomit contained urea, 
yet the urea secreted daily by the kidneys and stomach together was 
very far indeed below the normal. For a period of twelve days it 
amounted from both these sources to only five grammes daily. M. 
Charcot remarks, in reference to such cases as this, that the escape of 
even a small quantity of urea in cases of calculous obstruction of the 
ureters often serves to ward oflP dangerous symptoms, and that doubt- 
less the same rule applies here ; but he further observes that there is 
probably in hysterical ischuria an impairment of the functions of as- 
similation which diminishes the total amount of urea and extractives 
to be discharged from the body. 

Of affections of the reproductive system little remains to be said be- 
yond what has been already discussed. Amenorrhea, inenorrhagia, 
and other menstrual disorders are no doubt frequent accompaniments 
of hysteria; but many hysterical women are quite free from them. 
Again, the hyperesthesia which is so common in various parts of the 
body in hysteria may affect the vulva or vagina and render the act of 
coition intolerable, whilst, on the other hand, lascivious feelings are 



HYSTERIA. 



1015 



occasionally strongly developed, and either induce in the patient a de- 
meanor, probably towards certain individuals, which far transgresses 
the bounds of womanly self-respect, or give a motive for feigning dis- 
ease of the sexual organs. It is not surprising that the mental obliquity 
of such patients should occasionally incline in this direction. 

Other affections which hysterical patients are apt to mimic are those 
of the spine, of the joints, and of the mamma. These have already been 
adverted to under the head of hyperesthesia. It need only be added 
that they often closely simulate inflammatory disorders of the same 
organs, and are apt to be mistaken for them; and that we must not 
hastily assume that a suspected hysterical affection of these parts is not 
hysterical because we discover, in addition to the pain and tenderness, 
more or less swelling. 

Spinal irritation is the name which has been given to a group of 
hysterical phenomena which have been particularly described by Mr. 
Teale and the Messrs. Griffin, and is still by many regarded as a dis- 
tinct affection. It is characterized by the presence of more or less con- 
siderable tenderness at some spot in the course of the spine, or more 
rarely generally throughout its whole length, and by pain or other 
nervous phenomena referred to those parts of the body whose sensory 
nerves are in relation with the tender spot, or to certain of the viscera. 
Moreover, pressure upon the tender spot aggravates, or it may be actu- 
ally induces, the phenomena in question. If the tenderness occupy 
the upper part of the cervical spine, the neuralgic pain associated with 
it affects the occipital region, or it may be even the distribution of the 
trifacial ; if it be a little lower down, the neck suffers ; if it occupy the 
situation of the cervical enlargement the pain is experienced mainly 
in the arms ; if it be present in the dorsal region then the parietes of 
the chest or abdomen suffer; if it implicate the lumbar enlargement, 
the pelvis and the lower extremities are the chief seats of pain. Further, 
the sensation of a lump in the throat, palpitation, dyspnoea, spasmodic 
cough, gastralgia, nausea and vomiting, irritability of the bladder, or 
suppression of urine are all apt to attend the spinal tenderness ; but 
the particular group of these complications appears to be determined, 
like the neuralgic pains, by the situation of the local spinal tenderness. 
In all respects besides those which have been enumerated, the symp- 
toms which the patients present are identical with those of other forms 
of hysteria, and indeed the phenomena of these affections are, if not 
common to both, inextricably interwoven. The course of the disease, 
moreover, is identical in all respects with that of hysteria. 

The diagnosis of hysteria is not always easy ; and yet if the patient 
be carefully watched from day to day it is difficult to remain very long 
in doubt. It is not, however, an unnecessary caution to remind the 
reader that not only does hysteria ape many diseases so as to be readily 
mistaken for them, but that other diseases often simulate the phenomena 
of hysteria and may be easily taken for it. There is always a great 
temptation to assume that nervous disorders which we do not under- 
stand, and obscure visceral affections, in females, are hysterical. Among 
diseases which may thus be mistaken for hysteria should especially be 
named chronic inflammatory conditions of the brain and cord, and 



1016 



DISEASES OF THE NERVOUS SYSTEM. 



tumors of the brain. In forming a diagnosis we must carefully con- 
sider all the features which the special affection from which the patient 
suffers presents, and how far and in what respects they differ from 
those of lesions of the same parts which are not of hysterical origin. 
We have already pointed out the more important of these distinctions 
in our description of the various complications of hysteria. We must 
look carefully also to the various complications which attend the main 
affection, or which supervene from time to time, or alternate with it ; 
for it rarely happens that a patient suffering from an hysterical joint or 
from hysterical hemiplegia or paraplegia, does not also at one time or 
another have an attack of aphonia, or of retention of urine, or a bout 
of intermingled laughing and crying, or a distinct hysterical fit; or 
that the original affection does not undergo some striking change, or 
shift to some other part. Lastly, we shall often be importantly aided 
in coming to a decision by careful observation of the demeanor and 
conduct of the patient, and of her general tone of thought and feeling. 
[The inhalation of ether may sometimes be advantageously resorted to 
for the purposes of diagnosis. During the stage of excitement preced- 
ing insensibility, the hysterical patient will frequently move the limb 
or limbs which just before seemed completely paralyzed. The same 
remedy may also prove of service in cases of phantom tumors of the 
abdomen, which, of course, entirely disappear under its influence. In 
some cases, indeed, ether has appeared to be of service therapeutically, 
by convincing the patients that no real loss of power exists.] 

Hysteria is very common ; and varies from a slight affection of little 
importance to one of such gravity that it renders the patient a lifelong 
invalid, and her existence a burden and a misery to herself and those 
about her. Fortunately the milder cases are by far the most common, 
and in many of these complete recovery takes place; in many recovery 
is so far complete that there only remains a liability to the outbreak of 
slight hysterical phenomena under special circumstances of ill-health or 
excitement. Xot unfrequently, however, patients suffer from hysterical 
vomiting, alternating it may be or associated with other hysterical 
symptoms, for years; or they remain hemiplegic or paraplegic and 
bed-ridden for one, two, ten, or twenty years; or they suffer from 
urinary disorders, or aphonia, or joint-affections for an equally indefi- 
nite period ; or they are the victims of constantly recurring violent fits. 
In some cases patients continue thus for life. It may be said generally 
that the longer the phenomena have persisted, the less likely is ultimate 
recovery to take place ; but it must never be forgotten that (unless any 
organic complication has arisen) there is always a possibility that the 
patient will get well, and not only get well, but get well suddenly. 
The patient who has been confined to her bed paralytic for years will 
perhaps, under the influence of some sudden impulse or mental or 
emotional excitement, recover the complete use of her limbs ; the 
patient who appeared doomed to lifelong voicelessuess will suddenly 
speak aloud in her natural voice. 

Pathology. — We do not pretend to give any account of the morbid 
anatomy of hysteria or of its pathology. On these heads little or noth- 



HYSTERIA. 



1017 



ing of any importance is known, and we do not care to speculate. It 
is, so far as we know, a purely functional disorder. 

Treatment. — The treatment of aggravated hysteria is exceedingly 
difficult, and all the more difficult that the patient's condition excites 
in those about her that sympathy which she craves ; and that con- 
sequently that judicious firmness of management which the medical 
man should exercise is apt to be resented not only by herself but by 
her friends. Nothing, indeed, is more injurious to such patients than 
the pity and the attention which they receive; they live for them, they 
lay their plans to attract them, and their moral and bodily condition 
deteriorate under their influence. On the other hand, the exercise of 
a judicious firmness is essential for their successful treatment; and this 
it is impossible for the medical man to accomplish unless he acquires 
the confidence, if not of the patient, at all events of those under whose 
control she is. For this purpose it is not necessary to be harsh, indeed 
harshness is likely to defeat its object ; but the respect, and if possible 
the confidence, of the patient should be acquired by the cultivation of 
kindliness and friendliness of manner with firmness of purpose. There 
should be on the part of the doctor a judicious blending of the suavitcr 
in modo with the fortiter in re. No doubt hysterical patients are ex- 
tremely disposed to exaggerate their symptoms. No doubt they do 
occasionally wilfully and grossly deceive those about them; but it must 
not be assumed that there is generally intentional exaggeration, still 
less that there is imposition. They do, as a rule, really suffer that of 
which they complain, and suffer more when their attention is directed 
to the ailing part. It is impossible in a brief space to lay down any 
rules with regards to the general treatment of these cases. No doubt 
it is important to improve the general health, to relieve dyspeptic 
symptoms, to cure anaemia, to regulate the catamenia, to see that the 
bowels act regularly, to insist on regular hours, good wholesome diet, 
and daily exercise, and it may be to order change of air and scene ; 
and especially it is important to make the patient take an interest and 
pleasure in some useful occupation or some intellectual recreation or 
study. But it must never be forgotten that, to use Sir Thomas Wat- 
son's words, " behind the moody, reserved, and tricky behavior there 
often lies some mental or emotional cause — some hope deferred or dis- 
appointed — which being ascertained, and capable of satisfaction and 
satisfied, the patient may be restored to her customary health." 

Among the drugs which have been employed with more or less suc- 
cess, or want of success, may be especially mentioned iron, zinc, vege- 
table tonics, assafoetida, and other fetid gum-resins and stimulants. 
Alcohol in various forms is often recommended by the medical attend- 
ant or had recourse to by the patient; but alcoholic beverages, chlo- 
ral, opium, and other narcotic medicines should be given or allowed 
with extreme caution, for the temporary relief which they give is very 
apt to lead to their habitual use and ultimate abuse. In the hysterical 
paroxysms very often nothing more is needed than to lay the patient 
down and unfasten her dress or anything tight about her neck ; the 
paroxysm may frequently, however, be cut short or prevented by the 
free use of cold water — by dashing it in quantity over the neck and 



1018 



DISEASES OF THE NERVOUS SYSTEM. 



face — or as Dr. Hare points out, by firmly closing the patient's nose 
and mouth for a time, or until her dyspnoea is such that she is com- 
pelled to draw a long breath. Less valuable than these measures, 
though not altogether to be despised, are the inhalation of sal-volatile 
or smelling salts, and the exhibition of ammonia, assafcetida, or ether. 

M. Charcot, besides pointing out the readiness with which hysterical 
paroxysms may be induced by pressure made in the region of one of 
the ovaries, shows that in these same cases powerful, regulated, and 
sustained pressure is generally efficacious in arresting the paroxysm, 
however violent it may be. 

The removal or relief of the various local phenomena of hysteria 
frequently demands special forms of treatment ; aphonia may be gen- 
erally cured by Faradization of the throat, effected either by placing 
one pole of the instrument within the throat and the other external to 
it, or by placing the poles on either side externally. Paralytic affec- 
tions are also very often benefited by the same treatment, or by the 
constant current. The frequent use of the cold douche is often also 
very efficacious. Dr. Reynolds especially recommends the application 
of narrow strips of blister around the affected limbs. The sudden 
cure of hysteria in any of its forms is almost always possible under the 
influence of some powerful emotional excitement. Thus a sudden 
alarm that the house is on fire will sometimes cause a woman who has 
been paraplegic for years to rush from her bed with the full use of her 
limbs ; the unexpected infliction of sudden and severe pain generally 
suffices to make the dumb cry out at the top of her natural voice ; the 
promise that if a long-closed hand opens by a certain day it shall have 
a valuable trinket placed in it generally calls for fulfilment. 



CATALEPSY, ECSTASY, AND OTHER CONDITIONS 
ALLIED TO HYSTERIA. 

A large number of curious nervous phenomena — motor, sensory, 
emotional, and intellectual — occur, which are difficult to describe save 
by the help of illustrative cases, difficult to classify, and difficult to 
attach to specific lesions or specific conditions of the nervous system. 
In a large proportion of cases they originate in powerful mental ex- 
citement, and more especially in such as is connected with religious 
fervor ; they sometimes also arise from imitation or moral contagion. 
Young persons, from the period of commencing puberty to the termi- 
nation of adolescence, and more particularly females, or males of emo- 
tional temperament, chiefly suffer. The patients are often distinctly 
hysterical, and not unfrequently hysterical paroxysms, and some of the 
various other phenomena which have been considered under the head 
of hysteria, complicate some of the conditions we are now about to 
describe, or alternate with them. Indeed, if we look to the exciting 
causes, to the class of persons who are most commonly affected, to the 
character of the symptoms, and to their frequent association with hys- 



CATALEPSY AND ECSTASY. 



1019 



terical phenomena, we can scarcely avoid regarding the affections under 
! consideration as varieties of hysteria. We believe that they generally 
i are so. In some cases, however, they seem to be related rather to 

chorea, epilepsy, or insanity. 

1. Rythmical and other Methodical Movements. — These present in- 
I numerable varieties of character. In some cases the patient performs 

unceasing oscillatory, undulatory, or rotatory movements of the head 
! and neck, or of the entire trunk. In some she is seized with an un- 
controllable impulse to run forwards or backwards. In some she is 
impelled from time to time to leap into the air. To the same class 
must be referred the violent rhythmical movements which attended 
the "dancing mania" which prevailed so largely in the Middle Ages. 

2. Catalepsy. — By this term is meant an attack of loss of sensation 
and of consciousness, attended with a remarkable stiffening of the mus- 
cles. The patient for the most part is attacked suddenly, after more 
or less mental or emotional disturbance; she becomes pale and corpse- 
like, the respirations being slow and tranquil, the pulse soft. She can- 
not be roused, and is entirely insensible to pain. But the most striking 
phenomenon is the stiffness of the muscles, which is such that the limbs, 
head, and neck, or features, when forcibly put into any position, how- 
ever constrained and unnatural it may be, or however difficult to be 
supported by the healthy muscles, retain that position for some length 
of time. But although the patient appears to be unconscious to exter- 
nal impressions, and to remember nothing of what happens during the 
attack, she will sometimes sing or talk whilst it is upon her, or indi- 
cate by her expressions the presence of pleasing or painful impressions. 
A cataleptic condition may also occur in patients who still retain their 
full consciousness. Cataleptic attacks may last from a few minutes to 
several days, there may be a single attack only, or they may recur with 
more or less frequency. 

3. Ecstasy is a condition in which the patient is absorbed in some 
all-engrossing fancy or delusion. It is the condition to which weak- 
minded persons are wrought under the influence of revivalist preach- 
ers, and in which they are sometimes impelled to plead frantically for 
pardon for their supposed misdeeds, are sometimes in a delirium of 
complacency and joy at their supposed enrolment among the saved. It 
is the condition into which those persons fall who believe that they see 
visions of Christ, of the Virgin Mary, of saints, or of angels, or who 
hold familiar intercourse with them, or who receive divine messages. 
It is the condition into which the medium is not unfrequently brought 
under the mesmeric influence. It represents the mental condition also 
of the dancing maniacs of the Middle Ages. The nature of the fan- 
cies or delusions under which such patients labor may, therefore, pre- 
sent the widest range of variety, and their effects on the mind all degrees 
of intensity. Their influence over the actions of the patient, moreover, 
is very various. Thus, while one will gesticulate violently and roar 
or scream his prayers or his denunciations, another will dance or sing 
or utter pious ejaculations, another will sit apart with an air of self- 
satisfaction or quiet happiness, and yet another will be transfixed or 
stunned, as it were, with intense anxiety or horror. In some of these 



1020 



DISEASES OF THE NERVOUS SYSTEM. 



cases the patient will remain motionless and apparently insensible to 
every external impression for days together. But generally they are 
not wholly insensible, and although the mind may not be capable of 
being diverted from its engrossing thoughts, the pupils will contract 
and the eyelids close under the influence of a strong light, sneezing and 
watering of the eyes may be induced by the application of ammonia or 
snuff, and the respiratory muscles may be made to act powerfully under 
the shock of a jugful of cold water. 

4. Double- consciousness. — A curious condition, allied to the last, is 
sometimes witnessed, in which the patient appears to have, as it were, 
a double life — the one her normal state of existence, in which she is 
fairly sensible, and knows and understands, and perhaps takes an in- 
terest in, everything that goes on about her; the other, a condition of 
ecstasy or somnambulism, in which her mind is under the dominance 
of delusions, and in which the same lines of thought and feeling and 
the same delusions are continued through the successive ecstatic parox- 
ysms, and in neither of which has she any recollection or knowledge 
of what occurs in her alternative condition. Occasionally these strange 
phenomena may be prolonged for years, the one state passing into the 
other almost suddenly several times a day. The waking condition, 
indeed, may form but a small portion of her existence, and may itself 
be attended with curious motor, sensory, or mental phenomena. 

Treatment. — In treating the various cases which have just been con- 
sidered it is important not to lose sight of the fact of their intimate 
relations with certain other nervous diseases, more especially epilepsy, 
hysteria, and insanity, of which, indeed, in the great majority of cases 
they may be regarded as mere varieties. Their treatment, therefore, 
resolves itself mainly into the treatment of these affections. Every- 
thing calculated to improve the general health of the body is indicated ; 
but if a cure is to be effected it is rather by judicious management than 
by medicines. 



TETANUS. (Trismus. Lockjaw.) 

Definition. — Tetanus is an acute and generally fatal disorder, charac- 
terized by painful tonic spasms of the voluntary muscles, and usually 
traceable to some local injury. 

Causation. — In the great majority of cases tetanus is due to some 
wound or other injury. It may originate in a simple bruise, a trivial 
graze of the skin, the wound inflicted by a mere splinter, or a clean 
cut. It is far more commonly, however, referable to injuries, such as 
compound fractures, attended with laceration or crushing. It is gen- 
erally stated that injuries of the extremities are much more liable to be 
followed by tetanus than injuries of the head and neck or trunk; but, 
as Mr. Poland justly remarks, wounds of the extremities are far more 
frequent than wounds of other parts, and it is probably on this account 
that they are assumed to be specially liable to this serious complica- 
tion. But climatic conditions also are largely concerned in the pro- 



TETANUS. 



1021 



duction of tetanus ; for the disease is much more common in hot than 
in cold or temperate climates; and although it so frequently super- 
venes on wounds received in battle, it occurs much more frequently 
when the wounded are exposed to cold and wet than under opposite 
circumstances. Indeed the idiopathic form of the disease, which is 
somewhat unfrequent, is usually referred, and probably with reason, to 
the influence of these latter agencies — agencies which also induce rheu- 
matism, pneumonia, and other internal inflammations. Tetanus may 
occur in either sex, and at any age. In the West Indies it is very 
common in newly-born children, in whom it is supposed by some to 
be due to the division of the umbilical cord ; and it occasionally hap- 
pens in women after parturition. It has been sometimes attributed to 
intestinal irritation provoked by worms or other like causes. The 
supervention of tetanus in the traumatic variety of the affection ap- 
pears to be wholly uninfluenced by the character of the changes going 
on in the injured part. 

Symptoms and Progress. — Tetanus comes on after injury at periods 
varying between a few hours and three or four weeks, most commonly, 
according to Sir T. Watson, between the fourth and fourteenth day. 
When the disease is due to exposure the symptoms always supervene 
very quickly — occasionally in the course of a few hours. 

The first symptoms of which the patient complains are usually pain 
and stiffness of the muscles of the jaws and neck — symptoms which 
he probably refers to cold, 'and describes as sore throat and stiff neck. 
He has difficulty in opening his mouth, in masticating, and in moving 
his head, which is soon followed by difficulty in swallowing, and by 
spasmodic attacks of pain and aggravation of his difficulties provoked 
especially by every attempt to use the affected muscles. By degrees 
the stiffness and tendency to painful spasm extend to the other volun- 
tary muscles : to those of the back, which by their action on the trunk 
tend to curve the body backwards ; to the inspiratory muscles, and 
especially to the diaphragm, the implication of which involves more 
or less difficulty of respiration, and occasional attacks of more severe 
dyspnoea attended with acute pain striking through from the ensiform 
cartilage to the interscapular region ; to the muscles of the abdomen, 
which get rigid and knotted ; to those of the extremities, which be- 
come difficult of flexion, and from time to time powerfully and vio- 
lently extended; and to those of expression, which by their tonic 
contraction impress upon the patient's features a fixed painful look 
(the risus sardonicus), which becomes intensified during each recurring 
spasm. The muscles of the tongue and eyeballs, and those which 
move the hands and feet usually escape or are implicated late and to a 
slight extent only. 

As the disease progresses all the implicated muscles become more or 
less permanently stiff, and this condition, moreover, increases. But 
from the beginning the patient is liable to paroxysmal attacks, during 
which all his symptoms are enormously aggravated, and which come 
on at irregular but diminishing intervals, sometimes every quarter of 
an hour, sometimes every ten, or even every five minutes, and last 
individually from a few seconds to several minutes. These occur for 



1022 



DISEASES OF THE NERVOUS SYSTEM. 



the most part spontaneously, but are readily induced by any muscular 
effort, by moving the patient, or even by the slamming of a door and 
other such-like trivial causes. 

In the fully-developed disease, during the interparoxsymal periods, 
the patient probably lies stiff in bed upon his back. The muscles of 
the trunk, limbs, and neck are hard and rigid ; the jaws cannot be 
opened at all, or admit of being separated only to the extent of a few 
lines ; the face wears a painful expression, the brows being knit and at 
the same time transversely wrinkled, the eyes somewhat closed, the 
angles of the mouth drawn outwards and upwards, the lips apart, and 
the grooves extending from the ales of the nose towards the angles of 
the mouth deepened ; the mouth is clogged with saliva, which he has 
difficulty in swallowing; his voice is feeble, possibly reduced to a 
whisper; and his respirations are rapid and shallow. Further, he 
probably complains of more or less general pain or soreness, and especi- 
ally of pain extending from the scrobiculus to the back. During the 
occurrence of a paroxsym his sufferings become terribly aggravated, 
and frightful to witness. His arms and legs (especially the latter) be- 
come more strongly extended and widely separated ; the extensor mus- 
cles of the spine arch the trunk and the head and neck powerfully 
backwards, so that not unfrequently the patient rests only on his head 
and heels ; the respiratory muscles become more or less fixed, respira- 
tion difficult, and the face pale, livid, or ghastly ; the distortion of the 
features, moreover, is now extreme — the forehead is corrugated by the 
combined action of the frontales and corrugators, the eyeballs are fixed 
and staring, the eyelids rigid and partly closed, the nostrils dilated, 
and the angles of the mouth drawn outwards and upwards so as to 
impart that peculiar appearance of grinning which has been referred 
to. The lips moreover are separated, exposing the clenched teeth, 
between which bloody saliva occasionally flows in consequence of the 
accidental wounding of the cheeks or tongue by the sudden closure of 
the teeth upon them at the commencement of the paroxysm. The 
paroxysms are said frequently to commence with increase of the dia- 
phragmatic pain; and during their continuance cramp-like pains of 
the most agonizing character pervade the contracted muscles. 

Certain other phenomena to which it is desirable to draw attention 
present themselves in the course of tetanus. The pulse is for the most 
part rapid and feeble, and its rapidity and feebleness increase with the 
progress of the case, and are especially observable during the parox- 
ysms. At such times also the skin, which is generally moist or per- 
spiring, breaks out into profuse sweats. The urine is for the most part 
scanty and the bowels are constipated ; but the patient has entire con- 
trol over the bladder and rectum. According to Dr. Senator, there is 
no increase of the excretion of urinary solids. In the great majority 
of cases he retains his senses unimpaired throughout his illness, and is 
perfectly conscious up to the moment of death. He seldom sleeps, or 
he sleeps only by snatches. Sometimes the spasms cease entirely 
during sleep. The temperature in tetanus is generally somewhat above 
the normal, and liable to irregular diurnal variations. It does not 
usually exceed 100° or 101°, but may rise from time to time, even in 



TETANUS. 



1023 



cases which ultimately do well, to 102°, 103°, or more. Nevertheless, 
when the temperature reaches or exceeds 103°, the symptoms must be 
regarded as of serious import. Occasionally, with the approach of 
death the temperature rises rapidly, and may attain an elevation of 
even 110° or 112°. Sometimes in the course of tetanus the tempera- 
ture becomes subnormal. 

When the tetanic spasms affect only or principally the muscles of 
j the jaw, the affection is often termed trismus, or lockjaw. When, as 
| usually happens, the body becomes during the tetanic spasms arched 
backwards, the condition is termed opisthotonos. In those rare cases in 
t which, owing to the predominant action of other muscles, the body is 
curved forwards or to one side, the condition of emprosthotonos or 
pleurosthotonos, as the case may be, is present. 

The prognosis of tetanus is very gloomy ; almost all traumatic cases, 
and the great majority of idiopathic cases, die. According to Mr. 
Poland, taking all forms together the mortality is at the rate of about 
88 per cent. The most rapidly fatal cases, according to the same 
writer, are fatal in four or five hours. But death has been delayed 
until the thirty-ninth day. More than half the total number of fatal 
cases prove fatal during the first five days. Death is usually caused 
either by asthenia or apncea, or by a combination of these conditions. 
It not unfrequently occurs suddenly in one of the spasmodic attacks, 
and is then probably due immediately to spasm of the respiratory mus- 
cles, and possibly to those of the glottis. 

Tetanus may be simulated by hysteria, by inflammatory affections 
of the spinal cord, and especially by the effects of strychnia and other 
allied drugs. As regards the first two classes of disease, there can 
rarely be any real difficulty in distinguishing between them and teta- 
nus, in consequence in the one case of the supervention of paralysis or 
other signs of organic lesion of the cord, in the other case of the asso- 
ciation of various hysterical phenomena with the spasmodic muscular 
rigidity. Strychnia-poisoning, on the other hand, may be readily con- 
founded with tetanus. The chief distinction between them lies in the 
fact that (to quote Dr. Christison's words) " the fits of natural tetanus 
are almost always slow in being formed, while the nux vomica brings 
on perfect fits in an hour or less." Further, tetanus rarely, if ever, 
" proves so quickly fatal as the rapid cases of poisoning with nux 
vomica." It need scarcely be added that the history and aetiology of 
all cases in which tetanic spasms are present should be investigated 
with extreme care. 

Morbid Anatomy. — Various lesions have been discovered in the 
nervous system in cases of fatal tetanus. In the traumatic disease 
the nerves proceeding from the injured part have been found swollen, 
hyperssmic, and inflamed, either in part or in their whole length. In 
many cases, however, no such evidence of disease of the nerves has 
been perceived. It was formerly believed that the spinal cord was 
healthy ; but recent investigations, and more especially those of Drs. 
Lockhart Clarke and Dickinson, have demonstrated the presence, in 
some case at least, of considerable dilatation of the small vessels (par- 
ticularly the arteries and veins) with accumulation of blood within 



1024 



DISEASES OF THE NERVOUS SYSTEM. 



them and with more or less abundant translucent or finely granular 
exudation around them, infiltrating the tissues, and tending to accumu- 
late here and there, especially in the fissures, and occasionally upon the 
surface of the cord. With these changes are sometimes associated more 
or less disintegration of the proper nervous elements, and sometimes 
local effusion of blood. In trismus neonatorum congestion of the spinal 
arachnoid is described, with effusion of serum, and even extravasation 
of blood, into the subarachnoid tissue. It can scarcely, however, be 
admitted that these lesions have been proved to be invariably present 
in tetanus. That the motor nuclei of the spinal cord and medulla ob- 
longata are generally in a state of polarity or abnormal irritability, or 
that they are generally under the influence of some abnormal condition 
which excites them to unwonted action is clear enough. But whether 
this excited action is due to some peculiar change in the nerve-cells 
themselves, or to the influence exerted upon them by the congestion 
and effusion which surround them, or to the presence in the blood of 
some endopathic poison (as is suggested by Sir T. Watson and by Dr. 
Richardson) resembling strychnia in its effects, are points upon which 
as yet we can only speculate. It is at present, therefore, uncertain 
whether the lesions vhich have been discovered in the spinal cord are 
in any degree the cause of the tetanic spasms, or whether they are 
merely secondary to them. Ruptures of the muscular fibres are fre- 
quently seen after death from tetanus. They are common among the 
muscles of the back, but sometimes occur in the abdominal muscles 
and in those of the extremities. 

Treatment. — No treatment, so far as we know, has any curative in- 
fluence over tetanus. A certain number of cases get well under the 
most unfavorable circumstances; the great majority die in spite of the 
most strenuous efforts to save them. Innumerable drugs have been 
employed, and, according to their several advocates, with more or less 
success. Among those which have acquired the greatest reputation are 
opium, mercury, woorara, calabar bean, and chloroform. Many other 
medicines, for the most part sedatives, have also been recommended, 
especially, perhaps, aconite, belladonna, digitalis, tobacco, hydrocyanic 
acid, chloral, and turpentine. By some authorities, drastic purgatives 
have been lauded, by some, profuse stimulation by means of ether or 
alcohol. It is important to know that tetanic patients can take large 
doses of the most powerful sedative medicines, and drink large quan- 
tities of alcoholic beverages without being brought under the influence 
of these agents. Warm baths, cold baths, ice to the spine, bleeding, 
division of the nerves leading to the injured spot, and even amputation 
of the limb or part on which the injury was inflicted, are measures 
which have each in turn been adopted and abandoned. 

As regards general rules of treatment, we cannot do better than 
quote Sir T. Watson's words. He says: " Since any, the smallest, 
movement or impression made upon the surface, or upon the senses, 
will bring on the severer degrees of spasm, it is of primary importance 
to protect the patient against those sources of trouble, so sure to aggra- 
vate his sufferings, and so likely to augment his danger. Hence, if 
bloodletting should be thought advisable, it should be done early, 



CONGESTION AND ANEMIA. 



1025 



sufficiently, and once for all." " The same remark applies to the fre- 
quent use of purgatives. The bowels should be well cleared in the 
outset, and then let alone. The patient should lie in a darkened room, 
from which noise also should, as much as possible., be excluded. He 
should not be surrounded by a multitude of friends or attendants. He 
should be enjoined to speak, to move, to swallow, as seldom as he can. 
In the severe traumatic cases, the nerve, in my judgment, should be 
promptly divided, and as high up in its course as may be practicable ; 
and in all cases, there being no special indications to the contrary, I 
should be more inclined to administer wine in large doses, and nutri- 
ment, than any particular drug. If the tendency to mortal asthenia 
can be staved off, the disturbance of the excito-motory apparatus may 
perchance subside or pass away/' It must be added that the patient's 
sufferings may often be alleviated by the use of opium, or of chloro- 
form inhalation. 



CONGESTION. ANAEMIA. SUNSTROKE. 

Congestion and Ancemia. 

Symptoms. — So many nervous phenomena are commonly referred to 
congestion or anaemia of the nervous centres, that we can scarcely pre- 
sume to pass these conditions over in silence. And indeed, although 
we are disposed to assert that the great majority of cases in which 
symptoms are referred in practice to congestion or anaemia are not true 
examples of anything of the kind, it must be freely admitted that con- 
gestion and anaemia of the brain and cord do really play an important 
part in the phenomena of disease in the organs. Whenever inflamma- 
tion or other processes of proliferation are in progress congestion is 
necessarily present. We see the evidences of former congestion in the 
condition of the bloodvessels and of the parts immediately bounding 
them in chorea, in epilepsy, in tetanus, and in cases of chronic insanity. 
In heart-disease, in chronic bronchitis, in cases in which tumors press 
upon the large veins at the root of the neck, during violent muscular 
efforts, in the attacks of hooping-cough, the brain also becomes more or 
less congested. Anaemia may be the consequence of abundant losses of 
blood ; it may be due also to obstruction in the course of the common 
or internal carotid, or of one of the arteries distributed to the brain. 
But in the majority of the above cases, either the symptoms which the 
patient presents are not those which are commonly attributed to con- 
gestion or anaemia, or those referable to these conditions are inter- 
mingled and confused with others dependent upon causes of a different 
kind. 

We shall not discuss the various symptoms, which on theoretical 
grounds may be attributed to cerebral and spinal congestion. It will 
be sufficient for our purpose to point out that they will necessarily 
differ materially according as the congestion is acute or chronic, and 
according as it involves certain regions of these organs or pervades 

65 



1026 



DISEASES OF THE NERVOUS SYSTEM. 



them generally ; that abnormal congestion, if it be not excessive, is 
likely to be attended with exaltation of function ; if it be excessive, is 
pretty certain to induce perversion or abeyance of function, such as 
vertigo, headache, delirium, convulsions, coma, paralysis, muscae, and 
dimness of sight, noises in the ears, and dulness of hearing. The 
effects of temporary congestion are sometimes well seen in attacks of 
spasmodic cough, such as accompany hooping-cough, and the presence 
of thoracic aneurisms. In these cases the patient during his attack 
becomes more and more livid in the face, suffers from vertigo, headache, 
muscae, and noises in the ears, and presently becomes momentarily in- 
sensible, with probably some convulsive twitchings or spasms of the 
muscles of the eyeballs and of those of expression. 

The symptoms referable to anaemia will, equally with those due to 
congestion, vary according as the anaemia is general or partial, acute 
or chronic, slight or extreme. The symptoms, moreover, are in this 
case very much of the same kind as those which attend congestion. 
Thus, in cases in which the supply of blood to the brain is suddenly 
interrupted either by obstruction of one or more of the arteries sup- 
plying it, or by the temporary arrest of the heart's action, or by copious 
loss of blood, insensibility and convulsions frequently ensue ; and again, 
upon anaemia more slowly produced, it is not uncommon for delirium 
resembling that of chronic alcoholism, or for acute mania, or for apo- 
plectic symptoms to supervene. 

It must be added that, in many of the cases in which cerebral anaemia 
or congestion has been diagnosed during life, the condition of the brain 
appears to have been perfectly healthy ; and that in some there has been 
found, from no obvious cause, accumulation of fluid in the ventricles or 
subarachnoid tissue. Hence it is possible that, in some cases at least, 
the symptoms referred to congestion or anaemia may really have been 
immediately due to the presence of serous effusion. It is possible, also, 
that in some cases they may be referable to the effects of undetected 
poisonous matters in the blood. Without venturing to decide upon 
what conditions of the brain each of them depends, we shall proceed 
very briefly to discuss two or three so-called functional disorders of 
this organ, which appear to belong to the group of affections we are 
now considering. 

1. Delirium Tremens. — We have already (page 568) fully described 
this affection as occurring in drunkards ; but it occurs also, though 
much less frequently, independently of alcoholism, and indeed in per- 
sons of abstemious habits, sometimes as a consequence of severe injury 
(delirium traumaticum), sometimes as a result of long-continued mental 
anxiety. The symptoms and progress of the disease are identical in 
all these cases, and need not be again detailed. 

2. Insanity. — Various forms of insanity, more especially perhaps 
mania, melancholia, and dementia, are apt to come on during conva- 
lescence from acute febrile diseases, and after profuse haemorrhages. 
Their symptoms are in no way distinguishable from those of the same 
forms of insanity occurring under other conditions. They generally, 
however, end in more or less rapid recovery. 

3. Eclampsia. — The convulsive attacks which may attend these 



CONGESTION AND ANEMIA. 



1027 



conditions vary from mere momentary spasms of the muscles of the 
eyeballs or face, or some other limited part of the body, attended 
with momentary loss of consciousness, up to epileptiform seizures of 
the most violent kind. And, indeed, there is nothing in the attacks 
themselves by which they are distinguishable from those of true 
epilepsy. The differential diagnosis must rest upon the associated 
phenomena of the case, and upon its history and progress. 

4. Apoplexy and Paralysis. — The apoplectic attacks which appear 
to be due to merely functional disturbance of the brain have in many 
respects a close resemblance to those which are the result of haemor- 
rhage. Their onset is sometimes sudden, but is more commonly 
gradual, the patient becoming drowsy, then incompletely comatose, 
and finally, perhaps after remissions, passing into a condition of com- 
plete stupor. When the apoplectic condition is fully established, the 
patient is absolutely insensible ; his pupils are probably dilated and 
inactive to light ; he has lost the power of deglutition in a greater or 
less degree; his breathing is probably explosive or stertorous; his 
arms and legs are motionless and flaccid ; he has no control over his 
emunctories; and his urine is retained. The phenomena may, how- 
ever, be as varied as those due to sanguineous effusion ; and scarcely 
any of the symptoms which have been enumerated may not fail in 
certain cases, or be replaced by others. Especially it must be recol- 
lected that partial or general convulsions may occur; that the limbs, 
instead of being flaccid, may be rigid ; and, indeed, that there may be 
distinct hemiplegia. The main distinctions between functional apo- 
plexy and that from effusion of blood reside in their usually different 
modes of onset; in the paralysis, which in the former case is mostly 
general and attended with flaccidity; in the pulse, which is usually 
accelerated in the affection now under consideration; and in the tem- 
perature, which here generally rises from the commencement of the 
attack, whereas in cerebral haemorrhage it more usually, for some 
hours at least, falls. 

Comatose attacks of the kind above described are not limited to 
elderly persons; they are somewhat common in the course of such dis- 
eases as lateral and disseminated sclerosis ; and affections not clearly 
distinguishable from them are occasionally observed in young children, 
in whom they simulate the phenomena of meningitis. 

In connection with the apoplectic attacks, and occasionally inde- 
pendent of them, various paralyses may occur, sometimes hemiplegia 
sometimes of more limited range. Affections of the sensory nerves also 
may supervene, and the patient may have dimness or loss of vision, or 
analogous conditions involving the sense of hearing. 

It need scarcely, perhaps, be said that in each of the above cases the 
progress of the affection may closely simulate that of the malady which 
in its symptomatic phenomena it most closely resembles ; that in many 
instances complete recovery takes place within a shorter or longer time ; 
that in some instances relapses occur after such recovery ; that in some 
permanent mental defect or paralysis follows; and that not unfre- 
quently death ensues. 

Treatment. — It is impossible to lay down any definite rules for the 



1028 



DISEASES OF THE NERVOUS SYSTEM. 



treatment of these various functional disturbances. In the majority of 
cases the treatment should no doubt be the same as that for the affec- 
tions which they resemble. It is, however, important to bear in mind 
that if they be traceable in any degree to losses of blood, to want of 
food, or to anaemia however produced, it becomes essential to support 
the patient's strength by food and tonics. 

(Sunstroke. Coup de Soleil. Calenture. Insolatio.) 

Definition. — By the term " sunstroke " is usually implied a more or 
less sudden attack of unconsciousness, occurring in persons exposed, 
under adverse conditions, to high temperature. It seems highly prob- 
able, however, that more than one affection is included under this term. 

Causation. — Sunstroke appears to result from prolonged exposure to 
intense heat, especially if the atmosphere be at the same time damp and 
impure, and the patient be exhausted by long-continued overexertion, 
and by the wearing of clothes and accoutrements which impede the free 
action of his respiratory muscles. It often occurs, especially in tropical 
climates, from exposure to the direct rays of the sun ; but it is common 
also even in the night-time among persons who are subjected to intense 
heat in close, overcrowded, and ill-ventilated barracks, houses, or ships. 
Soldiers engaged in long and toilsome marches under the glare of a 
tropical sun are especially liable to suffer. 

Symptoms and Progress. — Sunstroke is sometimes sudden in its onset, 
but is more frequently preceded by premonitory symptoms. In the 
former case, the patient, who is probably engaged in some laborious 
occupation and exposed to the sun, suddenly falls down insensible and 
collapsed, with pale, cold, moist skin, gasping respiration, and extreme 
feebleness and rapidity of pulse. There is no doubt that, in these cases, 
equally with those next to be considered, the internal temperature at 
the time of the attack is above the normal. Death under these circum- 
stances not unfrequently takes place with great rapidity, or even quite 
suddenly. 

The premonitory or early symptoms of the other variety of the affec- 
tion comprise, in a large proportion of cases, great sense of weariness 
and prostration, with vertigo, nausea, dryness and heat of skin, ten- 
dency to frequent micturition, or even incontinence of urine, and rest- 
lessness or sleeplessness. The actual attack is sometimes ushered in 
with drowsiness, and the patient lays himself down to rest or sleep ; in 
other cases he is seized with momentary delirium or mania, more rarely 
with convulsions. Under any circumstances the patient rapidly be- 
comes comatose or apoplectic, and then presents most of the ordinary 
phenomena of this condition. He is perfectly insensible ; his pupils 
are contracted and unaffected by light, his conjunctivae injected; he 
breathes rapidly, noisily, and sometimes stertorously ; his pulse becomes 
frequent, small, weak, and often irregular; his face is pallid; and his 
skin intensely hot. In some instances the patient lies perfectly quies- 
cent during his comatose condition ; in others he is attacked with local 
or general convulsions of more or less severity. If death take place it 
is rarely delayed beyond twenty-four or forty-eight hours. 



SUNSTROKE. 



1029 



The mortality from sunstroke is very heavy, exceeding 40 per cent. 
Recovery is sometimes sudden and complete ; it is more commonly, 
however, slow, and attended for some few days by feebleness of the 

| heart's action and oppressed breathing, and is then not unfrequently 
followed by consequences of more or less importance, among which may 

! be enumerated headache, chorea-like affections of the muscles, epilepsy, 

i and some degree of mental imbecility. These sequelae may be per- 

] manent. 

Morbid Anatomy and Pathology. — In most cases of fatal sunstroke 
I the blood is found to have remained uncoagulated ; the lungs are in- 
i tensely congested, and the right side of the heart is loaded with blood ; 
further, there is generally more or less engorgement of the vessels of 
the brain. The proximate cause of the disease is uncertain. By some 
it is considered that the symptoms are due to the circulation of poison- 
ous matters in the blood. It is suggested by Dr. George Johnson that 
the intense heat of the body is attended with dilatation of the capilla- 
ries of the lungs, engorgement of these organs, and apncea, upon which 
the other phenomena of the disease presently supervene. The first 
symptoms, however, in many cases, are those of unconsciousness, and 
in all coma rapidly supervenes, with involvement of those organs es- 
, pecially which are in relation with the pneumogastric nerves. The 
symptoms differ indeed little, if at all, from those which constitute the 
typical apoplectic state ; and it is difficult therefore to believe that they 
are not primarily cerebral. 

Treatment. — Indian practitioners are unanimous as to the danger of 
bleeding in these cases, and are equally unanimous with respect to the 
value of the cold douche, or of cold applied in other forms. Espe- 
cially it seems advisable to apply cold to the head. Subsequently, if 
consciousness do not return, the head may be shaven, and counter- 
irritants used. It is desirable that the bowels should be made to act, 
but not that they should be violently purged. Generally, also, it is 
better to give nourishment and diffusible stimulants than to deplete. 

[Foreigners are the victims of sunstroke in such a large proportion 
of the cases occurring in this country, that, in addition to the causes 
mentioned by the author, a certain amount of influence has been at- 
tributed by American physicians to want of acclimatization. Thus, out 
of sixteen cases treated under the writer's direction in the wards of 
the Pennsylvania Hospital, during the summer of 1868, the patient, in 
one case only was an American. In estimating the importance of want 
of acclimatization as a predisposing cause of sunstroke, due weight 
must, however, be given to the fact that the greater part of our out- 
door hard labor is done by Irishmen, who are thus peculiarly exposed 
to the action of the sun's rays. 

A temperature of 108° Fahr. has not unfrequently been noted in 
sunstroke, and cases are on record in which it has exceeded 110°, but 
these are rare. The body also loses its heat very slowly after death, some 
observers even asserting that a slight increase occasionally takes place. 
In severe cases there is complete suppression of urine, and petechia? 
appear on the surface of the body, which is said by Dr. H. C. Wood 
to exhale a peculiar odor, by which the nature of the disease may often- 



1030 



DISEASES 0E THE NERVOUS SYSTEM. 



times be recognized. The pupils, which are at first contracted, become, 
as death approaches, dilated, and sometimes unequally so. 

If death take place a few hours after the beginning of the attack, 
and an examination be made without much delay, the heart is observed 
to be rigidly contracted. Dr. H. C. Wood has shown that the same 
condition is produced in animals if their temperature be raised artifi- 
cially a few degrees above the normal point. This contraction of the 
heart he believes to be due to the coagulation of the cardiac myosin, 
a result which is favored by a high degree of heat. The heart, how- 
ever, will be found flaccid if the attack has been a prolonged one, or 
if the autopsy has been deferred until putrefactive changes have set in. 

The presence of hyperpyrexia, together with many of the lesions it 
produces, has led many to form the opinion that the nature of sun- 
stroke is that of a fever, and it has consequently been proposed to call 
it "Heat," or "Thermic Fever." Dr. Wood, who is an advocate for 
this view, holds that heat produces the fever by paralyzing a hypo- 
thetical centre, situated either in the medulla or higher up, whose 
province it is to influence, through the vaso-motor or other nerves, the 
heat production in the body. But it would seem that at least equally 
strong arguments could be advanced for considering the condition fol- 
lowing certain injuries of the spinal cord a fever, since these not un- 
frequently give rise to a marked increase of temperature. 

The treatment should consist in the employment of all remedies 
which are capable of causing a rapid removal of the excessive heat, 
and these will include not only cold douches and effusions, but baths 
of ice-water. If these are not obtainable, the patient's body should 
be thoroughly rubbed with ice, while pieces of ice are placed about his 
head. When convulsions occur, hypodermic injections of morphia 
should be administered. These will often yield very good results, and 
may also be used when the patient is restless or excitable. Out of the 
sixteen cases above referred to, all of which were treated by rubbing 
with ice, but one case proved fatal, which is a much better result than 
has been obtained from any other method of treatment. In those cases 
of exhaustion from heat in which the thermometer indicates a low tem- 
perature, stimulants and the hot bath should be employed.] 



MEGRIM. [Migraine. Hemicrania. Sick Headache.) 

Definition. — A form of headache, for the most part circumscribed, 
coming on in paroxysms, and frequently attended with sickness, affec- 
tion of the sight, and other nervous phenomena. 

Causation. — Megrim appears in a large proportion of cases to be an 
hereditary disease, and when of distinctly hereditary origin, not un- 
frequently commences during the period of the second dentition, from 
wdiich age up to thirty it usually first declares itself. It rarely com- 
mences after thirty, and generally, even in those who are liable to it, 
subsides with advance of years. Patients do not often suffer from it 



MEGRIM. 



1031 



after fifty. Females are somewhat more prone to megrim than males. 
The determining causes of the attack are very various. As amongst 
the most common may be enumerated disturbance of the digestive 
organs, such as arises from overfeeding or prolonged abstinence ; 
uterine disorders — the catamenial period; sustained mental labor or 
excitement ; emotional disturbance ; bodily fatigue or want of exer- 
cise; insufficient or overabundant sleep; overcrowded .rooms ; foul 
air ; and meteorological conditions. And, besides these, various im- 
pressions upon the senses, such as are produced by glaring lights, rapid 
successions of objects presented to the eye, loud or discordant noises, 
strong odors, and offensive smells. Megrim, or a condition which is 
undistinguishable from it, may also arise in the course of an ordinary 
catarrh, or may be induced by exposure of the head to a current of 
cold air, or by the malarious poison. 

Symptoms and Progress. — In the simplest and most common form 
of megrim, the patient is attacked, more or less suddenly, with dull 
pain, usually referred to a limited surface immediately over the eye or 
in the temple. This gradually extends in area, and becomes more 
intense, but usually still remains limited to one side of the head. It 
varies in intensity from time to time, is for the most part aching, but 
is not unfrequently attended with sudden shootings, and generally with 
throbbing, which is always greatly increased by bodily or mental ex- 
ertion. It not unfrequently involves the eye, and this, together with 
the scalp, becomes more or less hypersesthetic or tender. In many 
cases the pain affects both sides of the head, although it is even then 
generally more intense on one side than the other; occasionally it 
attacks the occipital instead of the frontal region, and sometimes it 
becomes generally diffused. With the commencement of the headache 
the patient grows dull and indisposed for, or incapable of, mental or 
bodily exertion, which conditions gradually increase upon him, and he 
becomes pale and chilly, and looks heavy, dejected, and miserable. 
Not unfrequently the patient has a vague dread or sense of impending 
evil, and especially he is apt to experience a general feeling of profound 
illness, attended with tremulousness, shivering, and weakness of the 
limbs. The pulse is for the most part small and weak, and is often 
slower than natural. After a variable time a sense of nausea super- 
venes, and in a large proportion of cases culminates in more or less 
severe vomiting, during the attacks of which the headache generally 
attains its greatest degree of intensity. After the vomiting has ceased 
the patient probably goes to sleep, and at the end of some hours awakes 
in pretty nearly his usual condition of health. 

In a very large number of cases, however, other symptoms are asso- 
ciated with those which have just been considered, and for the most 
part precede them. Among the most interesting are disorders of 
vision. These are probably always, in those cases in which they mani- 
fest themselves, the earliest in the sequence of events. They vary in 
character ; in some cases certain portions of the retina? become simply 
insensible, and if the central spots of the eyes be involved, the patient, 
who probably feels well in all other respects, notices that he cannot 
see the nib of the pen with which he is writing, or the letters which he 



1032 



DISEASES OE THE NERVOUS SYSTEM. 



is forming, or that, while distinguishing all other parts of the body, he 
cannot see the face of the person at whom he is looking; in some cases 
he observes a tremulous, vibratile, or rotatory movement in some part 
or other of the field of vision * and sometimes these tremulous arese or 
spectra become variously colored. It is important to observe that the 
patches of retinal anaesthesia, or derangement, appear always to occupy 
identical parts in both eyes, that they vary in shape and form from 
time to time, that the coloration of the spectra, when it occurs, is 
always secondary, and that generally the ocular disturbance vanishes 
with the supervention of headache. Double vision sometimes occurs. 

Other senses are apt to suffer, but on the whole much less frequently 
than sight, and the phenomena referable to them, when associated with 
ocular derangements, seem always to come on after them. Occasion- 
ally deafness or noises in the ears are complained of, or loss or perver- 
sion of taste or smell, but more frequently perhaps the patient is attacked 
with numbness, passing on, maybe, to complete anaesthesia of the upper 
extremity, of the half of the head and neck and face, and even of the 
parts within the mouth, all on the same side as the cephalic pain. 
This loss of sensation is sometimes associated with more or less com- 
plete muscular paralysis. It may be added that the cephalalgia is not 
unfrequently associated with the presence of distinct neuralgic pains, 
not only at the back of the head, but in the back and side of the neck, 
and even in the shoulder and down the arm. 

It has already been observed that the patient always becomes more 
or less dull and apathetic and incapable of intellectual exertion ; but 
in some cases psychological phenomena of a more remarkable kind 
ensue. Sometimes there is marked mental confusion or incoherence of 
thought, and occasionally, indeed, aphasia of the most typical descrip- 
tion. Drowsiness is very common, sometimes forming one of the 
earliest indications of the attack ; sometimes coming on during its 
progress, and culminating in a more or less prolonged semicomatose 
condition ; but much more frequently constituting the termination of 
the attack. 

The attack of megrim comes on in many different ways. In some 
cases it supervenes immediately upon exposure to its exciting cause, as 
when the characteristic headache attacks the sufferer while he is at the 
theatre, or at a picture-gallery, or while he is being distressed with 
discordant noises or offensive smells, or while he is engaged in some 
laborious mental occupation. Not unfrequently it comes on during 
the night, the patient waking from time to time with the consciousness 
of heaviness in the head, and getting up with the attack well devel- 
oped ; or it manifests itself when he wakes in the morning, or immedi- 
ately after rising. In other instances it comes on at various times of 
the day, without obvious immediate cause. In a large proportion of 
cases the headache is the first symptom ; in many, however, this is pre- 
ceded by some of the prodromal phenomena above considered — the 
patient experiences a sense of general illness, or of depression or dread, 
or he has numbness, or confusion of thought, or extreme drowsiness, 
or other of the psychical phenomena which have been enumerated, or 
he has some affection of vision. It is curious that, as we have already 



MEGRIM. 1Q66 

shown, when these several phenomena, or any of them, manifest them- 
selves, they almost invariably precede the headache. It must he added 
that the attack may be limited to any one of these symptoms. 

The duration of megrim generally varies between twelve and twenty- 
four hours ; it may, however, last an hour or two only ; and it may be 
prolonged, but generally by successive relapses, for several days. The 
subsidence of the attack in some cases takes place gradually ; in a large 
number of cases it is preceded by vomiting ; but in the great majority 
(whether vomiting have taken place or not) the patient after awhile 
sinks into a profound sleep, from which he wakes refreshed, and 
probably well. The patient during convalescence often perspires pro- 
fusely, and excretes a large quantity of urine. 

Megrim is essentially a periodical disease, and in those who are 
liable to it not unfrequently comes on with more or less regularity 
once a week, once a fortnight, or once a month. It not uncommonly, 
however, occurs less regularly and more distinctly in response to cer- 
tain definite causes to which the patient exposes himself. Moreover, 
it often ceases for a time under various circumstances, and occasionally 
is only developed at long intervals in connection with special causes of 
ill health. 

Pathology. — Megrim has often been regarded as essentially an affec- 
tion of the liver or stomach ; and no doubt affections of these viscera, 
but more particularly of the stomach, must be regarded as one of its 
exciting causes. But, on the other hand, the attacks so frequently 
arise independently of any morbid condition of the digestive organs 
that we are compelled to look elsewhere for the seat of the complaint. 
It has latterly been referred to disorder of the cerebral circulation due 
to the influence of the vaso-motor nerves on the vessels of the part 
supposed to be implicated. Dr. Latham believes that its primary 
cause is some affection of the vaso-motor nerves, in virtue of which the 
vessels become contracted and the tissues anaemic ; and that it is to 
anaemia thus produced of the central nervous organs that the defects 
of vision and other early phenomena are due. And he refers the head- 
ache, which it must be observed is generally if not always attended 
with manifest dilatation and throbbing of the temporal arteries, to 
secondary hyperemia. Dr. Liveing, however, points out that even if, 
as seems not improbable, some of the phenomena are referable to 
ansemia and hyperemia, there must still be some antecedent cause to 
which the vaso-motor affection itself must be due. And he contends 
that the phenomena of the disease depend on the irregular accumula- 
tion and discharge of nerve-force; that the immediate antecedent of 
the attack is a condition of unstable equilibrium, and gradually accu- 
mulating tension in the parts of the nervous system more particularly 
concerned ; and that the paroxysm itself may be likened to a storm. 
He regards as the seat of disease the optic thalami and all those parts 
which lie between these bodies and the roots of the vagi. Megrim 
would seem, according to this hypothesis, to have a close pathological 
relation with epilepsy. The diseases do not, however, pass one into 
the other. 

Treatment. — In the first place it is very important for the patient to 



1034 



DISEASES OF THE NERVOUS SYSTEM. 



avoid those conditions to which in his case the attack of the disease 
seems to be traceable; it is especially important for him to live whole- 
somely, and to avoid ^astro-intestinal disturbance, to take plenty of 
exercise, to inhale the fresh healthy air of the country, and to refrain 
from too prolonged or intense mental labor, worry, or excitement. 
Various remedies are employed, reputedly with more or less success, to 
prevent the occurrence of the attacks of megrim • among others, iron, 
zinc, arsenic, iodide, bromide and chloride of potassium, quinine, 
strychnia, belladonna, hvoscyamus, and valerian. During the parox- 
ysms, nothing is so efficacious as complete rest in the recumbent pos- 
ture, in a perfectly quiet and darkened room. Relief may often be 
afforded, however, by the administration either of strong tea or coffee, 
or of a dose of caffein or thein, or by the exhibition of guarana. 
Occasionally a full dose of brandy, or of ammonia, or of one of the 
fixed alkalies benefits the patient. Local applications are often of great 
service, especially evaporating lotions, belladonna, or aconite. The 
aconitia ointment is especially valuable in many cases in warding off 
or subduing the headache. But such measures, although they relieve 
pain, do not prevent or curtail the other phenomena of the attack. 
The headache may sometimes also be relieved by pressure in the neck 
upon the carotid artery of the affected side. 



MENIERE'S DISEASE. (Aural Ver&go.) 

Definition. — A disease characterized by sudden attacks of vertigo in 
association with lesions of the semicircular canals. It was first recog- 
nized and described by M. Meniere in the year 1861. 

Causation and Pathology. — Experiments performed on the lower 
animals, in the first instance by Flourens and subsequently by other 
observers, have distinctly proved that injuries inflicted on the semi- 
circular canals are always followed by vertiginous movements, which 
have some definite relation to the particular canal operated upon. Thus 
injuries to the horizontal canals provoke a tendency to rotation of the 
head from side to side, and, if one only be affected, to rotation towards 
the affected side; whereas injuries to the superior and posterior canals 
cause upward and downward vertiginous movements, with a tendency 
to fall forwards if the superior canals only be implicated, and a ten- 
dency to fall backwards if the posterior only suffer. Flourens considers 
that in respect of their influence over such movements the horizontal 
canals mutually oppose one another; and that the superior canals op- 
pose the posterior. It may be added that Dr. Ferrier believes that 
irritative affection is followed by movements which are the exact con- 
verse of those above specified. 

The semicircular canals, whether concerned in audition or not, would 
seem therefore to be the organs of the sense of equilibrium. If this be 
so, it is only natural to assume that diseases of these organs should be 
attended with impairment or loss of that sense. 



Meniere's disease. 



1035 



Many cases have now been recorded in which the group of symp- 
toms presently to be considered has been found associated with more or 
less impairment of hearing ; and in several of them post-mortem exam- 
ination has revealed the presence of disease strictly limited to the semi- 
circular canals, which have been found filled with inflammatory exuda- 
tion. There is good reason, however, to believe that similar effects 
may be produced indirectly in diseases of the middle ear or other neigh- 
boring parts, by the pressure which is then apt to be exerted upon the 
contents of the labyrinth, and hence on the semicircular canals. The 
latter condition may result from exposure to cold, and may indeed com- 
plicate ordinary forms of otitis. 

Symptoms and Progress. — The specific phenomena of Meniere's dis- 
ease are sometimes preceded by deafness, earache, or other indications 
of aural mischief. But in a considerable number of cases they manifest 
themselves without any such prodromata. The patient is then sud- 
denly attacked with noises in his ears, or in one of his ears, and a feel- 
ing of vertigo — symptoms which are attended with or soon followed by 
faintness, pallor of face, perspiration, nausea, and probably actual 
vomiting. The attack is of short duration, sometimes lasting two or 
three seconds only ; and the recovery of the patient from it in many 
cases appears for a time to be complete. 

The noise is, as above stated, sometimes referred to one ear only, 
sometimes to both ; but in the latter case it is generally more pro- 
nounced on one side than the other. It differs in intensity in different 
cases, and is variously described as buzzing, humming, whistling, sing- 
ing, and is sometimes likened to the puffing of a steam-engine, some- 
times to a sudden explosion. The sense of vertigo varies in its severity 
and duration ; in some cases there is a mere momentary feeling of gid- 
diness, or a feebler but more prolonged sensation which resembles that 
which attends sea-sickness ; in some cases the patient feels as if he were 
suddenly thrown forwards and backwards or laterally, or rotated, and 
he staggers or falls in the direction which corresponds with his sensa- 
tion, clutching at neighboring objects for support, or actually falling to 
the ground. The attack is always attended with a sense of anxiety or 
alarm and more or less faintness. The latter condition may reveal 
itself by a momentary pallor, precordial anxiety, and failure of the 
cardiac action, or by all the ordinary signs of well-marked syncope, 
followed by perspiration, and by extreme rapidity and feebleness of 
pulse. A feeling of nausea is probably always present in a greater or 
less degree ; but not unfrequently actual vomiting presently ensues, and 
with its occurrence the attack usually comes to a close. 

It is important to bear in mind that the vertiginous seizure, however 
severe it may be, is never attended with actual loss of consciousness ; 
and that there is never any convulsive movement, any paralysis, any 
implication of speech, any squinting, any sensation which can be likened 
to the epileptic aura, or indeed any phenomena, beyond those above 
described as constituting the attack, which in any sense point to the 
presence of cerebral mischief. Headache even is unfrequent. 

The vertiginous attacks come on in the first instance at irregular and 
probably distant intervals ; but they tend gradually to increase in fre- 



1036 



DISEASES OF THE NERVOUS SYSTEM. 



quency and to approach one another ; and sooner or later, probably, a 
time arrives when the patient is never free from some degree of vertigo, 
though still suffering also from more or less frequent exacerbations or 
paroxysms. 

The noises in the ear which attend the early attacks of vertigo are 
not necessarily associated with deafness ; indeed, sometimes hearing is 
preternatural ly acute, and discordant or loud noises are peculiarly pain- 
ful to the patient. Occasionally the range of audition becomes con- 
tracted. At this time it also not unfrequently happens that no affec- 
tion of hearing is observable between the attacks ; but by degrees the 
noises in the ear become constant, though undergoing exacerbations 
when the paroxysms occur ; and the sense of hearing grows gradually 
more obtuse, until ultimately absolute deafness of the affected ear 
probably ensues. It is a curious fact that, with the supervention of 
absolute deafness, not only do the paroxysmal attacks cease, but with 
them the continuous sense of giddiness which had probably also 
been present. 

There is no doubt that slight and momentary attacks of giddiness, 
essentially resembling those above described, are by no means uncom- 
mon in connection with various temporary or permanent affections of 
the middle ear, and that they are then not unfrequently immediately 
induced by loud or discordant noises, or by other powerful impressions 
on the senses. In such cases, however, complete recovery is by no 
means unfrequent, and the disease rarely takes the course which has 
been above sketched. 

Treatment. — It is impossible to lay down rules for the treatment of 
Meniere's disease. It is important, however, to bear in mind that the 
vertiginous attacks are relieved though not prevented by lying down, 
and in many cases by carefully protecting the patient from all noises 
and other such influences. Further, it is obvious that when the 
symptoms depend on the presence of any disease of the accessible parts 
of the ear, treatment directed to these parts should be employed. 



LOCAL PAKALYSES. 

Paralysis of the Third, Fourth, and Sixth, or Oeulo-motor Nerves. 

Causation. — Paralysis of these nerves is very rarely due to disease of 
the opposite side of the brain, but almost invariably the consequence of 
some lesion involving them either at their origin or in some part of 
their course. Among such lesions may be named syphilitic disease of 
the base of the skull or contiguous parts of the brain ; tubercle, car- 
cinoma, or other forms of morbid growth, or inflammatory exudation, 
occupying these same situations; some tumor or accumulation of fluid 
or of blood situated in the superincumbent brain-substance, and caus- 
ing pressure ; and aneurisms or tumors in the course of the cavernous 
sinus. Oculo-motor palsy is common also in locomotor ataxy. 



PARALYSIS OF THE OCULO-MOTOR NERVES. 1037 



Symptoms and Diagnosis. — In order to determine the situation of 
the lesions causing the various oculo-rnotor paralyses, and to distin- 
guish the paralyses due to the separate nerves, it is essential, on the 
one hand, to have a clear view of the relations of these nerves at their 
origin and in the various parts of their course ; and, on the other hand, 
to have an exact knowledge of the normal actions of the muscles which 
the oculo-motor nerves supply. 

In reference to the anatomical point, it must be borne in mind that 
the nuclei of the third and fourth nerves are in close relation with one 
another in the floor of the iter, and that the sixth arises, in common 
with the facial, in the floor of the fourth ventricle ; that the muscles 
supplied by these nerves are seven in number, namely, the levator pal- 
pebral superioris, the four recti, and the two obliqui ; and that of these 
the external rectus is supplied by the sixth alone, the superior oblique 
by the fourth alone, and all the other muscles by branches of the third. 



Fig. 



hi 


\ 








\ / 




70° 











HORIZONTAL SECTION OF LEFT EYE SEEN FROM ABOVE. 

a a, Anteroposterior diameter of eye ; b b, transverse diameter of eye ; r r, fixed 
axis of rotation for movements effected by superior and inferior recti ; 
o o, fixed axis of rotation for movements effected by obliqui. . 



The muscles of the eyeball are six in number, and arranged in an- 
tagonistic pairs, which severally rotate the eyeball in opposite direc- 
tions upon an axis perpendicular to the plane in which they respec- 
tively act, and passing as nearly as possible through the central point 
of the globe of the eye. The several antagonistic pairs are the internal 
and external recti, the superior and inferior recti, and the superior and 
inferior obliqui ; and the axes of rotation of the eyeball which cor- 
respond to them (see Fig. 3) are (supposing the left eye to be under 
consideration, and its line of vision to be fixed directly forwards), for 
the external and internal recti, a vertical straight line passing through 
the centre of the eye ; for the superior and inferior recti, a horizontal 
straight line passing obliquely through the centre so that its nasal ex- 
tremity is a little in advance of its temporal extremity, and forming an 
angle of about 70° with the line of vision; for the obliqui, another 
horizontal straight line passing also obliquely through the centre, but 
in such a direction that it makes an angle of 35° only with the line of 



1038 



DISEASES OF THE NERVOUS SYSTEM. 



vision, its temporal extremity being just a little beyond the outer 
margin of the cornea, and its nasal extremity towards the back of the 
eye, a little internal to the situation of the optic disk. 

It may be assumed as sufficiently accurate for all practical purposes 
that the ball of the eye is globular ; that it is lodged in a socket bounded 
by fat, connective-tissue, and membrane, in which it moves as the head 
of the femur moves in the glenoid cavity ; that its centre of rotation is 
the actual centre of the eye ; and, further, as Helmholtz shows, that in 
consequence of the fixed origins of the oculo-motor muscles, and of 
their broad, fanlike insertions, the three axes of rotation which have 
been indicated remain unalterable in their relation to the fixed points 
of the orbit, no matter how much the line of vision — the line in which 
the eye is looking — becomes altered. 

Fig. 4. 



h 




b 



LEFT EYEBALL WITH IRIS AND PUPIL SEEN FROM THE FRONT. 

o, Anterior pole of axis of rotation for obliqui ; r, anterior pole of axis of rotation for superior and 
inferior recti ; b b, upper and lower poles of axis of rotation for internal and external recti. 

The concentric circles around o and r respectively indicate the direction and amount of movement 
of the different parts of the globe due to the action of the obliqui and superior and inferior recti 
respectively; the horizontal lines have a similar relation to the movements about the axis bb. 

It follows (see Fig. 4) from the above consideration : first, that the 
internal and external recti always cause the cornea to revolve around 
a vertical axis, to move therefore either in a horizontal equatorial line, 
or in proportion as it is elevated or depressed below this line in the 
arcs of smaller and smaller parallel circles ; second, that the superior 
and inferior recti always cause the cornea to revolve around the oblique 
horizontal axis, whose position has been already defined, and hence in 
the arcs of circles which are parallel to a vertical equatorial section of 
the eyeball, made through or near the outer margin of the cornea (as 
the eye looks directly forwards) in front, and the inner margin of the 
optic disk behind, so that the circles to which these arcs belong become 
smaller and smaller from the outer to the inner canthus of the eye, and 
the influence of the recti in causing vertical movements of the cornea 
correspondingly diminished ; third, that the obliqui always cause the 
cornea to revolve around the oblique horizontal axis which has been 
referred to these muscles, and hence in the arcs of circles which are 
parallel to a vertical equatorial section of the eyeball, made through 
or near the inner canthus ; the circles to which these arcs correspond, 



PARALYSIS OF THE OCULO-MOTOR NERVES. 



1039 



commencing in a point a little outside the outer margin of the cornea, 
| become larger and larger towards the inner angle of the eye, so that the 
! influence of the oblique muscles upon the cornea varies from the pro- 
I duction of simple rotation, when the eye looks outwards, to equatorial 
! amplitude of movement when the eye is directed towards the inner 
1 canthus. It follows further, that while all horizontal consensual move- 
| ments of the two eyes can be effected by means of the inner and outer 
1 recti only, all vertical consensual movements require the co-operation 
| of the superior and inferior recti and obliqui ; and all oblique move- 
■ ments the co-operation of all the muscles of the eyeball. We say all, 
| because the tonic contraction of the opposing muscles is necessary in 
! order to give precision to the efforts of those which are in action. 

Paralytic affections of the muscles of the eyeball are attended for the 
most part with squinting and double vision — the direction and char- 
acter of the squint being different for each muscle affected ; and the 
position of the object, as seen by the squinting eye in relation to that 
seen by the normal eye, being either internal or external to it, above 
or below it, or tilted. The existence of double vision is sometimes not 
recognized by the patient when the axes of his eyes diverge very widely; 
moreover, the double image tends to merge into one, and the squint to 
become unapparent, in proportion as the patient turns his sound eye 
in the direction towards which the squinting eye inclines. 

In testing the eyes with the object of discovering the existence of 
double vision and the peculiarities it may present, it is generally con- 
venient to place a colored glass before the affected eye, in order that 
the patient may be able to distinguish and indicate by their respective 
colors the two images which he sees. 

Assuming the left eye to be affected, the following would seem to be 
the consequences of paralysis of its several muscles taken singly : 

Internal Rectus. — Outward squint. Displacement of false image in 
horizontal line, to patient's right. Image not tilted. (See Fig. 5.) 

External Rectus. — Inward squint. Displacement of false image in 
horizontal line, to patient's left. Image not tilted. (See Fig. 6.) 

Superior Rectus. — Downward squint. Displacement of false image 
upwards. Elevation of pupil above horizontal line effected solely by 
inferior oblique ; its upward movement, therefore, is in a curve 
directed upwards and to the left; it is ample when the pupil is 
directed inwards, but w T hen the pupil is directed outwards, consists in 
a mere rotation of it upon its axis. Under these circumstances, the 
false image is tilted to the patient's right. (See Fig. 7.) 

Inferior Oblique. — Downward squint. Displacement of false image 
upwards. Elevation of pupil above horizontal line effected by supe- 
rior rectus ; its upward movement, therefore, is in a curve, directed up- 
wards and to the right ; it is most ample when the pupil is directed 
outwards. The false image, when the pupil is above the horizontal line, 
is tilted to the patient's left. (See Fig. 8.) 

Inferior Rectus. — Upward squint. Displacement of false image 
downwards. Depression of pupil below horizontal line, accomplished 
by superior oblique. Its downward movement consequently is in a 
curved line, directed downwards and to the left, being a mere revolu- 



1040 



DISEASES OF THE NERVOUS SYSTEM. 



tion upon its axis when the eye is directed outwards, but becoming 
more and more ample as the eye turns to the right. False image, when 
patient is looking downwards, tilted to his left. (See Fig. 9.) 

Superior Oblique. — Upward squint. Displacement of false image 
downwards. Depression of pupil below horizontal line, effected by 
inferior rectus. Its downward, movement takes place, therefore, in a 
curved line directed downwards and to the right, the movement being 
most ample when the eye is directed outwards, least ample when it 
looks inwards. When the pupil is below the horizontal line, the false 
image is tilted to the patient's right. (See Fig. 10.) 



Fig. 5. Fig. 6. Fig. 7. 




In the above diagrams the thick cross represents the true image, the thin cross the false image. 

It does not generally happen, however, that one muscle only is af- 
fected, unless it be the external rectus, or that when two or three mus- 
cles are involved they are completely paralyzed ; and consequently it 
becomes sometimes difficult to determine the respective shares which 
different muscles take in the patient's oculo-motor paralysis. It may 
be observed, however, that paralysis of the third pair very frequently 
causes ptosis, and also dilatation, with immobility of the pupil. When 
the oculo-motor branches of the third nerve are all implicated, the eye 
assumes an external squint, and the pupil is commonly directed also a 
little downwards. 

Treatment. — The treatment of paralysis of the muscles of the eye 
must be determined by the opinion we have formed of the nature of the 
lesion causing it. Iodide of potassium and mercury are indicated in 
syphilitic cases. Galvanism applied to the muscles, is sometimes ser- 
viceable. It is important to know that patients often recover from 
these paralyses. 

Paralysis of the Fifth Nerve. 

Causation. — This, like paralysis of the oculo-motor nerves, may be 
caused by various lesions implicating the nucleus of the nerve or the 



PARALYSIS OF THE FIFTH NERVE. 



1041 



nerve itself in some part of its course. It is most commonly of syphi- 
litic origin. 

Symptoms and Diagnosis. — The nerve may be implicated wholly or 
in part, and in the latter case the affection may be limited either to its 
ophthalmic, to its superior maxillary, or to its inferior maxillary divi- 
sion. When the affection is total, there is complete anaesthesia of all 
those parts to which the nerve is distributed, and at the same time com- 
plete paralysis of all the muscles of mastication which it supplies. The 
loss of sensation involves the anterior half of one side of the head 
and face as far back as the ear, inclusive of the conjunctiva, cornea, and 
eyelids, the mucous membrane of the nose, and that of the lips, cheek, 
gums, hard and soft palate, and tongue (excepting posteriorly in the 
neighborhood of the circumvallate papillae), and the external auditory 
meatus. The conjunctiva, consequently, is insensible to all external 
impressions, and liable, therefore, to become irritated into inflamma- 
tion ; its irritation, moreover, is unattended with reflex phenomena. 
The sense of smell becomes impaired, mainly on account of tendency 
to inflammation of the Schneiderian membrane, but partly in conse- 
quence of the failure (due to the affection of the sensory branches of 
the fifth) to appreciate the impression made by pungent vapors or gases. 
The sense of taste is lost in the anterior two-thirds of the tongue. And, 
partly in consequence of the total loss of ordinary sensation in one-half 
of the oral mucous membrane, mastication becomes difficult on the 
corresponding side, and the food tends to collect unknown to the pa- 
tient between the cheek and gums, or between the gums and tongue. 

The chief muscles which are supplied by the motor portion of the 
nerve are the temporal, the masseter, and the pterygoids. The tem- 
poral closes the jaw, and at the same time draws it more or less back- 
wards ; the masseter and internal pterygoid also close the jaw, but tend 
to draw it forwards ; the external pterygoid co-operates to some extent 
with the last, but is especially the muscle by which the jaw is thrown 
forwards. Collectively they close the jaw, and effect the various hori- 
zontal movements of trituration. If they be paralyzed, neither the 
temporal nor the masseter can be felt to harden in contraction as do 
those of the healthy side, w T hen the jaws are being firmly closed ; when 
the lower jaw is drawn backwards, it is drawn back obliquely with an 
inclination to the healthy side ; when it is protruded, it is protruded 
obliquely with an inclination to the paralyzed side. The last deform- 
ity becomes especially remarkable when the patient opens his mouth 
widely, for not only is the jaw then displaced in a very high degree 
towards the paralyzed side, but the oral orifice becomes lopsided, and 
the muscles connected with the affected side of the lower lip appear to 
act more powerfully than their fellows. The difficulty of masticating 
on the diseased side is necessarily largely dependent on the weakness 
of its muscles. 

We have referred to the tendency which the affected side has to be- 
come congested and inflamed. These conditions may supervene in the 
mucous membrane of the mouth or in that of the nose, or in the con- 
junctiva. It is most commonly observed, however, in the cornea, 
which is apt within a few days of the supervention of paralysis to be- 

66 



1042 



DISEASES OF THE NERVOUS SYSTEM. 



come opaque, to ulcerate, and to slough. These nutritive lesions 
doubtless obey the law which has been previously considered ; that is, 
they occur not so much when the continuity of the nerve is absolutely 
destroyed as when the implication of the nerve or of its nucleus is in- 
complete and irritative. Under the same circumstances, loss of elec- 
trical contractility of the paralyzed muscles and wasting of their tissue 
are likely to come on quickly. 

If the affection of the fifth nerve involve only one of its main 
branches, the paralytic symptoms will of course be limited to the dis- 
tribution of that branch. Accordingly, if the ophthalmic branch be 
alone affected, the anaesthesia will occupy the front of the forehead, the 
upper eyelid, the conjunctiva, and a part of the mucous membrane and 
integument of the front of the nose ; if the superior maxillary branch, 
the anaesthesia will involve the cheek, the lower eyelid, and upper lip, 
together with the side of the nose, a portion of the temple, the interior 
of the nose, and the mucous membrane of the cheek, upper gums, and 
palate ; if the inferior maxillary, the lateral part of the head and face, 
with the ear, the lower lip and gums, the tongue, and the muscles of 
mastication ; if the motor portion, the muscles of mastication only. 

Treatment. — If the disease be syphilitic, antisyphilitic remedies are 
indicated. But in other varieties of organic disease medical treatment 
can have but little influence. If the affection be hysterical, or due to 
inflammation or other removable causes, Faradization or galvanism may 
be serviceable in hastening the restoration both of sensation and of 
voluntary movement. 

Paralysis of the Portio Dura. (BeWs Paralysis.) 

Causation. — This may be caused by any lesion implicating the 
nucleus of the seventh nerve in the floor of the fourth ventricle, or in- 
volving the nerve in any part of its course thence, either as it passes 
through the substance of the pons, or between its apparent origin and 
the internal auditory meatus, or in its passage along the aqueduct of 
Fallopius, or just after its emergence from the petrous bone. It may 
be caused, within the skull, either by extravasation of blood, or by in- 
flammatory mischief, or by the formation of syphilitic or other growths; 
in its passage through the bone, either by fracture of the bone or by 
morbid growths originating within the substance of the bone, or in 
connection with caries of the internal or middle ear, or in consequence 
of inflammation attacking the nerve itself. Externally to the petrous 
bone, it may be due to injury, as sometimes happens to the infant 
during delivery by the forceps, or to inflammatory or other lesions of 
the parotid or other tissues in the vicinity. The most common and 
interesting cause of Bell's paralysis is inflammation of the nerve within 
the aqueductus Fallopii — a condition which is readily induced by 
allowing a draught of cold air to play on the side of the face. It thus 
not uncommonly follows on a railway journey in which the patient has 
been sitting facing the engine and next an open window, or the ex- 
posure of one side of the face while sleeping to a current of air. 

Symptoms and Diagnosis. — Inflammatory, or so-called " rheumatic " 



PARALYSIS OF THE PORTIO DURA. 



1043 



paralysis, is generally of rapid development, and is not necessarily 
attended with any pain or constitutional disturbance. Yet not unfre- 
quently the draught which caused the paralysis causes also earache, or 
some neuralgic phenomena referable to the fifth nerve. The symp- 
toms of Bell's palsy are very striking; all the* muscles supplied by the 
seventh of one side are more or less completely paralyzed, the half of 
the face, consequently, is motionless and expressionless, the wrinkles 
are smoothed away, and the predominant action of the opposite 
muscles draws the mouth more or less powerfully over to that side. 
When the patient wrinkles his forehead in surprise, the healthy half 
becomes, through the agency of the occipito-frontalis, transversely fur- 
rowed; when he frowns, the corrugator supercilii contracts the same 
side into vertical folds ; but in both cases the forehead on the affected 
side remains perfectly smooth. The orbicularis palpebrarum ceases to 
act, the eye remains consequently permanently open, and the con- 
junctiva, from the loss of its habitual protection, becomes watery and 
inflamed. M. Duchenne points out that this condition is sometimes 
associated with epiphora, and he attributes this circumstance to the fact 
that the tensor tarsi is then paralyzed as well as the orbicularis itself, 
and consequently fails to retain the puncta in the position best adapted 
for carrying off the lachrymal secretion. The ala of the nose becomes 
flaccid, and the corresponding nostril loses its rotundity. The cheek 
is motionless and smooth and limp ; the natural furrow beneath the 
eye and that which descends from the side of the nose become indis- 
tinct ; and when the patient coughs or blows through his mouth, the 
cheek, ow T ing to paralysis of the buccinator, becomes momentarily dis- 
tended. The mouth is drawn to the opposite side ; when it is shut, 
the paralyzed half closes less perfectly than the other ; w T hen it is 
opened, that half opens less completely ; and the more powerfully he 
exercises his facial muscles, as in laughing and crying, the more ex- 
treme does its lateral distortion become. He has lost the power of 
whistling, and probably that of blowing out a candle ; his utterance is 
somewhat impaired; he has difficulty in retaining fluids in his mouth, 
especially in the act of drinking; and food tends to collect between the 
teeth and the paralyzed buccinator. There is no ansesthesia. 

There are some important distinctions between paralysis due to direct 
implication of the portio dura, and paralysis of the same nerve of 
hemiplegic origin. In the first place, in hemiplegia the paralysis very 
rarely involves materially those branches of the portio dura which are 
distributed to the eyelids and upper half of the face, while in primary 
affection of the nerve the paralysis is general. In the second place, in 
hemiplegia not only is there more or less general unilateral palsy, but 
the motor branch of the fifth pair and the hypoglossal are generally in- 
volved together with the facial ; w r hile, in the other case, the temporal, 
the masseter, and the pterygoids still act perfectly, and the movements 
of the tongue are in no degree compromised. Lastly, in hemiplegia 
the facial paralysis is rarely absolute even in the parts chiefly affected, 
and the paralyzed muscles retain their bulk and electrical contractility, 
while in Bell's paralysis the loss of power is usually absolute, and the 
muscles lose their electrical contractility very rapidly, sometimes in 



1044 



DISEASES OF THE NERVOUS SYSTEM. 



less than a week. In neither case are the muscles of the eyeball and 
the levator palpebral implicated. 

The phenomena above enumerated are those which most commonly 
attend Bell's paralysis, and are the only ones which attend it when the 
lesion causing it is situated below the junction of the portio dura with 
the Vidian nerve; but other phenomena are apt to be superadded in 
proportion as the disease causing paralysis approaches nearer and nearer 
to the origin of the nerve. If the disease be so situated as to involve 
the chorda tympani and the petrosal nerves, the patient is likely to 
suffer : first, from more or less overacuteness or painfullness of hearing, 
which has been attributed to relaxation of the membrana tympani in 
consequence of paralysis of the tensor tympani, but is by Brown-Se- 
quard believed to be due to hyperesthesia of the auditory nerve de- 
pendent on involvement of the sympathetic branch supplying its blood- 
vessels ; second, from dryness of the half of the tongue corresponding 
to the paralyzed half of the face, and some impairment of taste, owing 
to the implication of the chorda tympani and consequent interference 
with the salivary secretion, and to some obscure influence exerted 
directly on the tongue;- and, third, from paralysis of the corresponding 
half of the soft palate, resulting from implication of the petrosal nerves. 
This paralysis is revealed partly by the fact that from involvement of 
the corresponding half of the azygos uvula?, the uvula when at rest, and 
still more when in motion, is so curved that its point is directed away 
from the paralyzed side ; and partly by the condition of the correspond- 
ing arch of the fauces. There is generally less readiness of movement 
under irritation ; moreover, the tensor palati, which should draw the 
more central part of the soft palate upwards, fails to elevate it to the 
level of the opposite side; the paralysis of the circumflexus allows the 
soft palate to fall generally a trifle below its normal elevation ; and the 
paralysis of the muscles of the pillars of the fauces diminishes their 
normal prominence, and interferes with their due projection towards 
the mesial line during the act of deglutition. Further, the tonic action 
of the muscles on the healthy side tends to draw the margins of the 
faucial aperture in that direction. 

When the paralysis is due to disease situated within the skull, va- 
rious other complications are liable to be associated with the affection 
of the portio dura ; and our diagnosis of the seat of the disease will be 
mainly determined by the nature of these complications. Thus if the 
disease be within or near the internal meatus, the auditory nerve is 
likely to be involved and deafness to be produced ; if it implicate the 
common nucleus of the sixth and portio dura, paralysis of the external 
rectus will complicate the facial palsy ; and if the disease be irregular 
in its distribution, or involve any considerable area, various other pa- 
ralyses, referable to implication of the nerves originating in the floor of 
the fourth ventricle, are liable to be present. 

Occasionally both facial nerves are simultaneously affected, or affected 
within a short time of one another, a condition which may involve 
some difficulty of diagnosis. 

The prognosis of paralysis of the portio dura will depend on the na- 
ture of the lesion to which it is due. That form of the disease which 



PARALYSIS OF THE SPINAL NERVES. 



1045 



results from exposure to cold for the most part ends favorably, some- 
times in a week or two, more frequently after four or five weeks, or it 
may be not until after the lapse of some months. An element in the 
prognosis is the condition of the electro-contractility of the paralyzed 
muscles; the more completely this has become annulled, the longer will 
recovery be delayed, and the greater is the fear that the paralysis may 
be permanent. M. Duchenne draws attention to the fact that not un- 
frequently permanent contraction of the muscles previously paralyzed 
takes place, and that thus consecutive deformities are induced. This 
happens he says, in those cases in which either spasms supervene in the 
paralyzed muscles under the influence of Faradization or other form of 
excitation, or a rapid return of tonic force takes place in muscles which 
remain paralyzed and deprived of their electrical contractility. Either 
of these occurrences foretells, according to this authority, the superven- 
tion of such contraction. The contraction sometimes affects one, some- 
times several muscles. When it involves the lesser zygomatic it curves 
and deepens the naso-labial line and gives an expression of chagrin ; 
when the greater zygomatic, it elevates the commissure of the mouth 
and imparts an aspect of gayety ; when the quadratus menti, it depresses 
and everts the lip ; when the orbicularis palpebrarum, it causes diminu- 
tion of the palpebral aperture; if all the muscles are involved, the side 
of the face becomes wrinkled, as if by cold. At the same time that 
the muscles contract, or it may be subsequently, they usually recover 
their voluntary power; but that is not always the case, and the con- 
tracted muscles may remain permanently paralyzed. 

Treatment. — In the treatment of paralysis of the seventh pair from 
cold, it is generally well (considering the serious results of permanent 
deformity) at once to adopt active measures; to apply a few leeches to 
the mastoid process, and to follow them up by fomentations, poultices, 
or equivalent applications. Subsequently blisters or other counter- 
irritants may be resorted to. If recovery do not follow these measures, 
galvanism should be employed. Duchenne thinks it better, in cases 
where the electric contractility has wholly disappeared, to delay the 
use of Faradization until after the lapse of two or three weeks. He 
recommends the employment of a current with rapid intermissions, and 
that the muscles should be directly and in turn excited. He points 
out that the paralyzed muscles regain their tonic power, and the face 
its symmetry in repose, two or three weeks or more before there is any 
indication of the return of voluntary power; and that it is usually in 
the zygomaticus major that this power first returns — a fact which may 
be ascertained by making the patient smile. When the muscles begin 
to contract, he recommends that the intermissions should be few and 
the sittings short and unfrequent, and especially he recommends this, 
if any of the precursory signs of permanent contraction manifest them- 
selves, in order that such contraction may be prevented. Galvanism 
is also efficacious in restoring the paralyzed muscles. 



Paralysis of the Spinal Nerves. 
Causation. — Paralysis of these nerves may arise under various con- 



1046 



DISEASES OF THE NERVOUS SYSTEM. 



ditions ; but we propose to refer only to those varieties which M. Du- 
cherme speaks of as paralysis from cold, and in which the paralysis is 
due to inflammation of the trunk of the affected nerve. These affec- 
tions are not uncommon, and may be readily mistaken for ordinary 
rheumatism. 

Symptoms and Diagnosis. — The symptoms comprise pain and tender- 
ness in the course of the affected nerves, and febrile disturbance, to- 
gether with the various consequences of disease involving mixed nerves, 
namely, on the one hand, burning or shooting pains in the course of 
the branches of the implicated nerve, and hyperesthesia followed by 
tingling and numbness; on the other hand, muscular paralysis, fol- 
lowed by speedy loss of electric contractility and wasting. The mus- 
cular paralysis for the most part comes on later than the symptoms 
referable to sensation. During the early period of the disease, the 
temperature in the affected parts is augmented, later on it undergoes 
manifest diminution. 

M. Duchenne singles out two forms of this affection for description, 
one of which he terms "deltoid rheumatism," the other "paralysis of 
the radial nerve." Affection of the spinal accessory is also not un- 
common. 

1. Deltoid rheumatism is essentially inflammation of the circumflex 
nerve. It is marked by the occurrence of violent neuralgic pains in 
the deltoid muscle, sometimes coming on in paroxysms, and augmented 
by any movement of the shoulder. In voluntary movements pain is 
especially excited in those fibres which are brought into contraction — a 
circumstance which will help to distinguish the affection from ordinary 
articular rheumatism. The symptoms may last for a few days only, 
or be prolonged for months. In many cases convalescence takes place 
without the occurrence of complications ; but in some cases, atrophy 
of the deltoid, or of some part of it, supervenes after the pains have 
continued for awhile ; and when at length, under these circumstances, 
the pains have subsided, the muscle continues atrophic, although 
retaining its voluntary and electrical contractility. In other cases pa- 
ralysis, attended with more or less complete abolition of electrical 
contractility, supervenes in the course of the disease. 

2. Paralysis of the radial or museido- spiral nerve is sometimes re- 
ferred to pressure on the nerve, occurring, for example, during sleep, 
but by M. Duchenne is attributed (like Bell's paralysis) to exposure to 
cold, especially to exposure of the arm during sleep to a current of cold 
air, or to cold and damp. It generally comes on suddenly, without 
pain or tenderness, but with numbness and tingling, extending to the 
tips of the fingers. The paralytic symptoms have a very close resem- 
blance to those of lead-poisoning, and, like these, comprise, as an essen- 
tial feature, dropping of the hand, and incapability of extending the 
fingers. The differences between them are, as M. Duchenne points 
out: first, that in paralysis from cold, the paralyzed muscles retain 
their electrical contractility unimpaired, whereas in lead-palsy this 
quality rapidly diminishes or disappears; second, that the supinator 
longus, which never suffers in lead-poisoning, is invariably implicated 
in the present case. The proof of implication of the supinator longus 



LOCAL FUNCTIONAL SPASM AND PARALYSIS. 



1047 



is obtained, according to M. Duchenne, in the following manner: "If, 
when the patient has placed his forearm in the position of semiflexion 
and semipronation, he attempts to flex it more completely (the at- 
tempt being opposed) the long supinator can neither be seen nor felt 
to contract. This is the indication of paralysis of this muscle, which, 
as I (M. Duchenne) have proved experimentally, is the flexor of the 
forearm while it occupies the semiprone position." As in lead-palsy, 
the flexor muscles of the forearm and hand and the interossei escape. 
Paralysis of the musculo-spiral nerve from cold is almost always 
followed sooner or later by recovery. In some cases, however, pro- 
gressive wasting of the affected muscles comes on ; and occasionally, 
also, the opposing muscles and the interossei become manifestly en- 
feebled from want of use. 

Treatment. — The value of galvanism in the treatment of the above 
forms of paralysis is very great. When the deltoid pains are unat- 
tended with fever or local signs of inflammation, M. Duchenne strongly 
recommends the use of cutaneous Faradization, effected upon a dry sur- 
face, with a feeble and slowly intermittent current. When, however, 
there is wasting or paralysis, Faradization of the muscles or the con- 
tinuous current is especially indicated, both in the case of the deltoid 
and in that of the muscles of the forearm. In both of these cases, 
moreover, frictions, stimulant applications, and blisters are often ser- 
viceable. When there is distinct evidence of inflammation, the various 
forms of galvanism are not only inefficacious, but injurious. The or- 
dinary remedies for local inflammation are then called for. 



LOCAL FUNCTIONAL SPASM AND PARALYSIS. 
WRITER'S CRAMP, WRY-NECK, ETC. 

Definition. — The affections here referred to are limited to a single 
muscle, or part of a muscle, or to groups of muscles, and occur only or 
mainly at the time when certain accustomed specific actions in which 
they are engaged are in process of performance — the affected muscles 
apparently acting normally under all other conditions, and in other 
respects seeming fairly healthy. 

Causation. — The causes of these functional derangements are ex- 
ceedingly obscure. They are, however, for the most part induced by 
the long-continued exercise, in special motor combinations, and the 
consequent fatigue of the muscles which afterwards become affected. 

Symptoms and Diagnosis. — The most common of the affections in- 
cluded in the present group are those which are known in this country 
as "writer's cramp," or "scrivener's palsy," and "spasmodic torti- 
collis," or "wry-neck." 

1. Writer's cramp affects, as its names imply, those who are engaged 
in writing, and more especially those whose avocations compel thera to 
write for many hours a day continuously for long periods of time. It 
generally commences with some sense of fatigue or pain in certain of 



1048 



DISEASES OF THE NERVOUS SYSTEM. 



the muscles of the hand or forearm, which comes on shortly after the 
patient has begun to write. This condition generally slowly increases 
upon him until the pain or weariness attends all his attempts to write, 
and compels him to rest for a time or to desist altogether. Sooner or 
later, and sometimes from the very commencement, some spasm or loss 
of power, coming on only when the patient is engaged in writing, 
seizes certain of the muscles which he is exercising, and renders his 
handwriting tremulous or jerky or arrests his operations completely. 
In the earlier stages of the disease, the patient sometimes opposes its 
influence with more or less success. But its almost inevitable tendency 
is to go on from bad to worse, until at length the use of the pen be- 
comes impossible. In some cases patients have been compelled to 
learn to write with the left hand ; but in many of these, unfortunately, 
this hand has after awhile become affected similarly to the other. 

The affection of the muscles is sometimes paralytic, the patient sud- 
denly losing his power over certain muscles, and dropping the pen 
from his hand ; in most cases it is spasmodic, the muscles causing 
tremulous or choreic movements, or sudden flexion, extension, or rota- 
tion. Different muscles are affected in different cases. In some in- 
stances they are the extensors and flexors of the index finger; in some 
the interossei of the second and third fingers; in some the muscles of 
the thumb; in some the supinators of the hand. Occasionally the 
muscles of the hand and forearm are all more or less involved. Some- 
times the spasm or paralysis commences in the deltoid or other muscles 
of the shoulder. And occasionally the affection extends from the 
muscles of the hand and arm to those of the head and neck and trunk. 
In the great majority of cases more or less sense of fatigue or pain ac- 
companies the functional motor disturbance — generally the patient 
complains of cramp in the muscles, occasionally of neuralgic pains. 
However extreme the paralysis or spasm becomes, the muscles retain 
their functional activity for all other movements except those which 
have induced them ; and there is very rarely any absolute loss of mus- 
cular power or any affection of the sensory nerves. 

2. Spasmodic wry-neck is an affection of adult life, and of either sex. 
It comes on for the most part insidiously with uneasiness or pain in 
the affected side, and a tendency to jerk the head as though to relieve 
some feeling of discomfort. By degrees the uneasiness increases, the 
spasmodic movements become more constant and more violent, and the 
head is habitually carried on one side. At first the patient can tempo- 
rarily restrain his spasms by a voluntary effort, and temporarily hold 
his head erect, or he can counteract the spasmodic contraction of the 
affected muscles by the voluntary action of the healthy muscles of the 
opposite side. But after awhile the head and neck become permanently 
twisted, and the clonic spasms which accompany this twisting are be- 
yond even temporary control. The spasm of the muscles of the neck 
is apt to become associated with similar spasm of the facial muscles or 
of those of mastication, or of those of the shoulder or arm. In the 
great majority of cases the spasms cease during sleep, or whenever the 
head is supported. Dr. Reynolds observes that the contracted muscles 
present increase of electric irritability and of electric sensibility. 



LOCAL FUNCTIONAL SPASM AND PARALYSIS. 



1049 



The muscles which are affected differ in different cases. In some 
instances they are those which rotate the atlas and skull upon the axis, 
and the movements of the head are those of simple rotation. Some- 
times it is the splenitis capitis which suffers, in which case the head is 
inclined downwards towards the affected side, and backwards, the face 
at the same time rotating towards the affected side, moreover the skin 
of the upper and back part of the contracted side of the neck is 
thrown into deep transverse folds. Sometimes it is the clavicular por- 
tion of the trapezius which is implicated, in which case, as in the last, 
the head is inclined downwards towards the affected side, and thrown 
somewhat backwards, but the face is rotated towards the opposite side. 
If the fibres of the trapezius which are attached to the shoulder are 
involved, this part will be distinctly elevated. Sometimes, again, the 
sterno- mastoid suffers, in which case, as when the trapezius is con- 
; tracted, the head is inclined towards the affected side, and the face is 
rotated towards the opposite shoulder, but, contrary to what happens 
in either of the other cases, the head is thrown forwards. It need 
scarcely be added that, although the several muscles which have just 
been named may be affected separately, it is more common to find 
groups of muscles implicated, and further, that the affected muscles 
can generally be readily recognized by their contraction and rigidity 
and spasmodic movements. 

3. Among examples of other similar conditions we may quote the 
i following, chiefly from M. Duchenne : A tailor, whenever he had made 
a few stitches, suffered from violent rotation of the arm inwards, in 
consequence of contraction of the subscapular muscle. A fencing- 
master, whenever he put himself into the posture of defence, was seized 
with rotation of the arm inwards, and violent extension of the forearm. 
A turner, whenever he attempted to work the lathe with his foot, suf- 
fered from spasmodic contraction of the flexors of the foot upon the 
leg. A gentleman, who also suffered from writer's cramp, became sub- 
ject, when he attempted to read, to contraction of the rotatory muscles 
of the head, which carried his head to the right. A literary man, who 
had been employed for some years in deciphering manuscripts, suffered 
after awhile from double vision, coming on a few seconds after he had 
fixed his eyes intently on any object ; the defect was due to spasmodic 
contraction of one of the internal recti. A student, who had over- 
worked himself, became the victim of a strange affection which ren- 
dered reading impossible, and finally impelled him to commit suicide. 
As soon as he began to read, he was seized with a painful constriction 
of the forehead, temples, and eyes, during which the eyebrows were 
I elevated by spasmodic contraction of the frontales, and the eyes closed 
I by the powerful action of the orbicu lares palpebrarum. Pianists are 
I liable to the same affection as writers are. Singers occasionally become 
I incapable of singing from involvement of the laryngeal muscles ; sol- 
I diers, of marching, from implication of the peroneus longus. In some 
cases the spasms affect the muscles of expression, in some, those of 
j expiration. 

Pathology. — The pathology of these functional affections is very 
obscure. Most writers believe that the primary fault is in the nervous 



1050 



DISEASES OF THE NERVOUS SYSTEM. 



centres, but Dr. Poore, in some very able papers on the subject pub- 
lished in the Practitioner, seems to prove conclusively that the disease 
in all its forms is due to abuse of the implicated muscles, which " be- 
come tired out, and degenerate into a condition of chronic fatigue or 
irritable weakness," and he shows also that, contrary to the general 
belief, the affected muscles are absolutely weaker than their healthy 
fellows, and that their electric irritability is diminished. 

Treatment has not usually proved satisfactory. In Duchenne's hands 
Faradization failed absolutely. Dr. Poore, however, has latterly ob- 
tained great success by the employment of the continuous current 
(which has considerable influence over nutrition), in combination with 
rhythmical exercise of the enfeebled muscles. His mode of using the 
current in writer's cramp is as follows: "One pole (the positive) is 
placed, let us say, in the axilla, and the other over the ulnar nerve, 
just where it leaves the edge of the biceps muscle en route for the ole- 
cranon. The strength of the current is short of that which causes 
muscular contractions, but is just sufficient to make the patient con- 
scious of a tingle in the end of the little finger when the circuit is 
made or broken. The patient is then made to exercise the interossei 
by separating and approximating the fingers rhythmically." The 
nerve to be galvanized and the muscles to be exercised will of course 
differ in different cases. Liniments and douches may also be employed, 
and tonics are generally indicated. But in all cases it is of the highest 
importance for the patient to abstain, in a greater or less degree, from 
all those habitual actions with which the muscular default is especially 
linked, and never to attempt to overcome it by violent efforts. Rest 
is essential. 



NEURALGIA. TIC DOULOUREUX. 

Definition. — By the term neuralgia is meant pain, for the most part 
paroxysmal, occurring in the course of nerves and in their arese of dis- 
tribution. 

Causation. — Neuralgia is the result of numerous different conditions. 
It may depend on injury to a nerve, such as arises from contusion, 
w 7 ounds, and the impaction of foreign bodies ; on pressure, as takes 
place when the bony channels through which certain nerves pass be- 
come contracted from any cause, or when nerves are compressed by 
tumors or other adventitious masses ; on the implication of nerves in 
disease, as, for example, when they are involved in rheumatic or other 
varieties of inflammation, in syphilitic formations, or in carcinomatous 
or other tumors. In some cases it appears to depend upon, or to be 
connected with, certain constitutional conditions, among others, the 
malarial cachexia, anaemia, and hysteria. In a considerable number 
of cases, and these are often, the most severe and incurable, no cause 
whatever, local or constitutional, can be discovered. Neuralgic affec- 
tions are said to be hereditary. This is no doubt true of specific forms, 
such as megrim, and possibly of tic, but can scarcely admit of satisfac- 



NEURALGIA. 



1051 



tory proof in respect of the heterogeneous cases which make up the 
great bulk of ordinary neuralgia}. 

It need scarcely perhaps be pointed out that neuralgic pains, which 
are sometimes of extreme intensity, attend a very large number of the 
diseases which have already been discussed: among others, tabes 
dorsal is, spinal caries, and more particularly carcinoma of the vertebrae 
or pelvic organs, and certain inflammatory affections of deepseated parts, 
such as abscess of the liver, calculous pyelitis, and hip-joint disease, in 
which the local affection is attended with neuralgic pain in some com- 
paratively remote part. 

Lastly, it is important to bear in mind that the lesion or local con- 
dition causing neuralgia may exist in the course of the implicated nerve, 
or may be seated in the spinal cord or brain, or (as above pointed out) 
may occupy some remote part from which its acts indirectly. 

[In this connection it is proper to introduce some reference to the 
views held by the late Dr. Anstie in regard to the pathology of neu- 
ralgia. In his opinion the morbid process, which consists in an atrophic 
change, was seated in the posterior roots of the spinal nerves or in the 
gray matter with which these are connected. The atrophy may be 
preceded by inflammation, but this is not necessary, as it may be pro- 
duced by long-continued alteration in the nutrition of the part, caused 
by peripheral irritation of the nerves. The amount of positive evidence 
in favor of this view, it must be confessed, is small ; there exists, how- 
ever, at least one observation tending to confirm it. In a case reported 
by Romberg, a man had suffered for several years from the most vio- 
lent and intractable trigeminal neuralgia complicated with interesting 
trophic changes of the tissues. Post-mortem examination showed that 
the pressure of an internal aneurism had almost entirely destroyed the 
Casserian ganglion of the painful nerve, that the trunk and posterior 
root of the nerve were in a state of advanced atrophic softening ; and 
that the atrophic process had extended in a less degree to the nerve of 
the other side. Moreover, in locomotor ataxia, in which the main ana- 
tomical change is a progressive atrophy of the posterior columns, which 
usually falls with peculiar severity on the posterior nerve-roots, or on 
the parts of the gray matter immediately adjoining them, neuralgia may 
be said to be a constant and most characteristic phenomenon.] 

Symptoms and Progress. — Neuralgia is essentially characterized by 
the occurrence of pain in the course and distribution of some one or 
more of the sensory nerves. The pain varies in character ; it may be 
tingling, aching, burning, boring, crushing, cutting, stabbing, darting; 
it may be more or less continuous, but usually occurs in sudden light- 
ning-like shocks, which come on either singly or in paroxysms made 
up of a larger or smaller number of such shocks ; and even when the 
pain is continuous it usually presents exacerbations presenting more or 
less of this latter character. The pain varies also in its intensity ; in 
its severest paroxysmal form the patient's sufferings are horrible — some- 
times he raves and stamps like a madman, sometimes screams aloud, 
sometimes utters half-suppressed groans, but under any circumstances 
is so absorbed in the intensity of his suffering that he appears almost 
unconscious of everything which is going on about him ; on the other 



1052 



DISEASES OF THE NERVOUS SYSTEM. 



hand,.it may consist in nothing more than a little tingling, creeping, 
or burning. This is often the case during the interparoxysmal stage 
of those cases in which there is never entire cessation from pain ; and 
such sensations often constitute the commencement of each paroxysmal 
attack. 

It very commonly happens that more or less tenderness or hyper- 
esthesia is associated with neuralgia; there may be tenderness along 
the course of the affected nerve, or there may be general tenderness in 
the area of its distribution, or spots of special tenderness scattered here 
and there upon that surface. It is a fact of considerable importance, 
first established by Valleix, and since confirmed by numerous observers, 
that in cases of neuralgia there are generally, if not always, specially 
painful spots, which are more or less characteristic for each nerve that 
may be involved, aud are determined mainly by the emergence of the 
nerve or of some of its branches from a bony canal, or by its passage 
through some dense fascia. Trousseau insists that one of these painful 
spots is the spinous process of that portion of the spine from which the 
painful nerve escapes. The neuralgic paroxysm may often be induced 
by irritation of the hypersesthetic parts, or even by touching them ; on 
the other hand, firm pressure upon them may relieve or avert it. 

Anaesthesia, again, is not unfrequent in connection with neuralgia. 
Sometimes more or less impairment of tactile sensibility or discrimina- 
tion goes along with considerable tenderness or hyperesthesia. But 
absolute loss of sensation in the affected area occasionally supervenes 
after a time. 

The sudden darts of intense pain which so commonly attend neu- 
ralgia are generally associated with more or less sudden reflex move- 
ments or twitchings of the part affected ; if the toe be attacked, the leg 
is momentarily drawn up by an uncontrollable impulse; if the finger, 
the arm; if the face (as in ordinary tic douloureux), spasmodic twitch- 
ing of the muscles of the painful region occur. These convulsive move- 
ments may vary from mere twitchings of the muscles to spasmodic 
contractions of considerable force. 

The above phenomena are apt to be complicated with other local 
manifestations. In many cases the affected surface becomes during the 
occurrence of the paroxysm more or less red and congested ; and not 
unfrequently obvious dilatation of the arteries and veins both in, and 
leading to or from, the implicated region takes place, attended with 
painful throbbing. In connection with congestion, there is apt also to 
be some temporary modification in the function of the affected area, such 
as arrest or increase of secretion, which is especially obvious if the con- 
junctiva or the mucous membrane of the nose or mouth be the part 
involved. 

Further, the various nutritive lesions, especially erythematous and 
herpetic eruptions, which have been previously referred to affections of 
the sensory nerves, are all apt to occur in connection with neuralgia. 
Occasionally also the hair over the affected region turns temporarily or 
permanently white. 

An interesting feature of neuralgia is the tendency to shift which 
it presents in many cases. Thus in trifacial neuralgia the paroxysmal 



NEURALGIA. 



1053 



attacks not unfrequently shift either from day to day, or it may be at 
distant intervals, from one branch of the nerve to another branch ; the 
pain may even shift to the great occipital nerve or to branches of the 
cervical or brachial plexus. 

Another important point connected with neuralgia, and one indeed 
which has been regarded as inseparable from true neuralgia, is its uni- 
lateral or unsymmetrical character. This characteristic, however, is 
not universal, and occasionally both arms or both legs are symmetri- 
cally and equally affected. 

In a large proportion of cases neuralgia is essentially intermittent ; 
the pains come on in paroxysms lasting probably from a second or two 
to a minute, rarely longer, which may recur every five or ten minutes, 
day and night, or may manifest themselves at longer and more or less 
irregular intervals. Occasionally they remit for weeks or months 
together. 

The general state of health of neuralgic patients presents considera- 
ble diversity, yet it is important in reference both to prognosis and to 
treatment to pay attention to this subject. Thus in some cases we find 
the patient ansemic, in some hysterical, in some laboring under the 
consequences of old syphilis; in some he is rheumatic, in some gouty, 
in some he is suffering from the effects of the malarious poison. But 
in a considerable number of cases, and these are often the most severe 
and most intractable, no general morbid condition can be discovered 
beyond that which the persistent neuralgia itself induces. In these 
latter cases the disease is not unfrequently quite incurable. 

Neuralgia may attack any of the sensory nerves, as well those sup- 
plying the viscera as those distributed to the skin. Among the former 
class may especially be named neuralgia? of the heart, stomach, kid- 
neys, uterus and ovaries, testes, and mammas. Among the latter class 
the more important probably are trifacial neuralgia or tic douloureux, 
and sciatica. 

1. Tie Douloureux, or as Trousseau terms it, epileptiform neuralgia, 
is at the same time the most severe and the most typical variety of 
neuralgia. It comes on in adult life, and is then for the most part of 
lifelong duration. Its causes are obscure: sometimes it is referred to 
carious teeth, sometimes to exposure to cold, sometimes to gastrointes- 
tinal irritation, sometimes to old age or failing health or malarious in- 
fluence. The neuralgic phenomena involve mainly or entirely certain 
of the branches of the fifth nerve of one side. In some cases it is the 
first division, in some cases the second, in some cases the third ; or it 
may be that certain portions only of these divisions are involved, more 
rarely the whole nerve. The pains, moreover, are apt to shift from 
time to time from one division to the other, or from certain fibres to 
certain other fibres. They vary in their character as other neuralgic 
pains vary ; but usually are burning or shooting, and occur in sequences 
of sudden electric-like shocks. They vary also in their intensity, from 
a mere sense of warmth or tingling to paroxysms of the most intense 
agony. They sometimes come on at rare intervals ; sometimes, on the 
other hand, occur every few minutes, night and day, and are then apt 
to be brought on by any movement of the affected parts, by pressure, 



1054 



DISEASES OF THE NERVOUS SYSTEM. 



by a sudden shock, or by even a breath of cold air. The patient there- 
fore, in some cases in which the second or third division is involved, 
finds it impossible to masticate, and almost impossible to take nourish- 
ment by the mouth. Under any circumstances the severity and fre- 
quency of the paroxysms are apt to vary from time to time; and 
occasionally, even in severe cases, the attacks intermit for comparatively 
long periods. In aggravated cases the paroxysms of pain are often 
attended with spasmodic contractions of the muscles of the affected 
region. Sometimes the patient smacks his lips, or chews, or executes 
other movements which are apparently voluntary, and performed with 
the object of relieving pain. More frequently he rubs his face during 
the paroxysm either with his hand or with his handkerchief, or with a 
pad that he carries in his hand for the purpose. This constant rubbing 
not unfrequently has the effect of wearing down the hair of the affected 
side — the whisker, the beard, the hair in the neighborhood of the 
temple — which then appears as if kept close shaven ; occasionally it 
even modifies the form of the side of the face. Further, the frequently 
repeated spasmodic action of the muscles of the affected side produces 
after awhile a permanent curiously wrinkled condition of the surface. 

Tic douloureux, unbearable though it appears to be, does not tend 
directly or necessarily to shorten life. Patients nurse their agony for 
many years. The only ways in which it can be regarded as inimical 
to life are by the difficulty which it occasionally opposes to the ingestion 
of food, and by impelling the patient to commit suicide. 

2. Neuralgia of the Nerves. — It seems needless to discuss the neu- 
ralgia? of the various other sensory nerves. Any sensory nerve may be 
affected in precisely the same way as the trifacial; and the affection 
may be every whit as unbearable and as intractable as tic douloureux 
itself. We may, however, recall attention to the fact that neuralgia is 
commonly associated with zona, sometimes preceding, sometimes accom- 
panying, sometimes succeeding the eruption; and that in the last case 
the pain is apt to continue for a considerable length of time, and occa- 
sionally becomes permanent, and is often exceedingly acute. We may 
also point out that one of the most common varieties of neuralgia is 
that which affects the great sciatic nerve. This frequently arises from 
exposure to cold, but may be due to many other causes ; it is occasion- 
ally attended or followed by some degree of anaesthesia, and occasionally, 
but mainly when due to structural disease, leads to wasting of the mus- 
cles. The pain is of true neuralgic character, and is greatly aggravated 
by movement of the implicated limb, or by pressure. It is in many 
cases exceedingly persistent and difficult of cure. 

Treatment. — In dealing with cases of neuralgia it is always of great 
importance to ascertain, if possible, the cause on which it depends, and 
then, if it be within our competence, to obviate or remove" it. If, for 
example, the neuralgic pain be traceable to the influence of the mala- 
rious poison, quinine or arsenic is indicated ; if it be connected with 
anaemia, iron is probably the best remedy ; if it be a consequence of 
exposure to cold or of rheumatism, the treatment suitable for these con- 
ditions should be employed ; if it be referable to syphilis, iodine and 
mercury are most likely to be serviceable ; and further, if it be depen- 



NEURALGIA. 



1055 



dent on the existence of some local morbid process compressing or 
otherwise involving the nerve, our treatment must be directed accord- 
ingly. 

But in a large number of cases, no such hints for treatment are af- 
forded us ; we can then, so far as general treatment is concerned, only 
deal with them empirically. Among remedies which, under these cir- 
cumstances, have been found useful, may be enumerated iron, quinine 
in large doses, oil of turpentine, chloride of ammonium, phosphorus, 
croton-chloral hydrate, aconite, Indian hemp, belladonna, and opium. 
Of these, opium, or its alkaloid, morphia, is by far the most valuable. 
Indeed, the severest cases of tic, and of similar forms of neuralgia in 
other parts, often find relief only from large and repeated doses of this 
drug, which may then be given by the mouth, or, preferably, by sub- 
cutaneous injection. If given by the mouth, in cases of this kind, it 
may be necessary, at length, having begun with small doses, to ad- 
minister as much as from twenty to sixty grains of morphia daily. Al- 
cohol is not unfrequently serviceable in relieving pain. Cases of the 
less severe forms of neuralgia are occasionally cured by a few glasses 
of wine, or by a tumbler of strong brandy and water. 

Local medication is often very valuable. Of course the several nar- 
cotics which have been enumerated, especially morphia and atropia, 
may be injected subcutaneously at the seat of pain. But, besides this, 
the application to the surface, or the inunction, of opium, belladonna, 
or aconite, often gives relief. The most valuable of these applications 
is aconite in the form of the unguentum aconitise. Counter-irritation 
also is frequently of much benefit, more especially by means of blisters, 
issues, the actual or galvanic cautery, and acupuncture. Galvanism is 
occasionally serviceable. Duchenne employed cutaneous Faradization, 
rendering the surface to which it is applied dry by dusting it with 
some powder, and then applying for a minute or so Faradization of 
considerable strength, and repeating the process according to circum- 
stances, from time to time. The continuous current is more commonly 
preferred. In this case w r ell-wetted sponges must be used, and the cur- 
rent employed must be of no greater intensity than the patient can 
readily bear. Moreover here, as in the other cases, the applications 
should be of short duration, and frequently repeated. Lastly, division 
of the affected nerve has often been practiced, especially in cases of tic 
douloureux. It cannot be asserted that this procedure ever absolutely 
cures the neuralgia ; but" there is no doubt that it very often effects a 
temporary cure — a cure lasting occasionally for some weeks or even 
for a few months. 



1056 ADDENDUM TO DISEASES OF THE VASCULAR SYSTEM. 



ADDENDUM TO DISEASES OF THE VASCULAR SYSTEM. 

To be read in connection with the Introductory Remarks to that Section. 

It was first shown by Friedreich, and has since been confirmed by 
other observers (and especially by Dr. Frederick Taylor in the Guy's 
Hospital Report, 1875), that hepatic pulsation is not unfrequent in 
certain forms of heart disease. It occurs mainly in those cases in which 
pulsation of the veins of the neck also occurs, and seems to be due to 
regurgitation into the vena cava ascendens, and thence into hepatic 
veins, in connection with incompetence of the tricuspid valve and hy- 
pertrophy and dilatation of the right side of the heart. It is hence 
mainly a remote consequence of lesions of the mitral valve. The pulsa- 
tion, which must be distinguished from ordinary epigastric pulsation 
due to the direct influence of the action of the heart, or of the abdomi- 
nal aorta, is visible over the whole extent of that portion of the abdomi- 
nal surface with w r hich the distended liver is in immediate relation, and 
may, in many cases (especially if the enlargement of the liver be con- 
siderable) be felt, on grasping the hepatic zone with the two hands, to 
be distinctly expansile. The sphygmographic tracing which may be 
obtained from the pulsating organ seems to indicate that its beats are 
essentially referable to the contractions of the ventricle, but that they 
are modified in some cases by the auricular systole. 



INDEX. 



Abdomen, regions of, 603 
Abdominal dropsy (see, Ascites), 685 

lymphatic glands, tubercle of, 643 

phthisis, 642 

typhus (see. Enteric Fever), 210 
Abortion in relapsing fever, 190 

in syphilis, 250 
Abscess, 54 

of brain (see Encephalitis), 910 

of heart (see. Carditis), 488 

of kidney (see Pyelitis and Nephritis), 
770, 772 

of liver (see Hepatitis), 714 

of lungs (see, Pneumonia), 389 

of pancreas, 750 

of spleen, 543 

retropharyngeal (see Retropharyngeal Ab- 
scess), 594 
Abstinence, as cause of disease, 24 
Acarus folliculorum, 333 

scabiei, 328 
Acborion Schoenleinii, 335 
Acne, 312 

causation of, 312 
desciiption of, 312 
indurata, 313 

treatment of, 314 
rosacea, 314 

treatment of, 315 
Active congestion. 101 

Acute (see Inflammation, and different dis- 
eases) 

Addison, Dr. T., on vitiligoidea, 319 

Dr. W., on migration of leucocytes, 39 
Addison's disease, 548 
causation of, 549 
definition of, 548 
moibid anatomy of, 549 
pathology of, 549 
symptoms and progress of, 550 
treatment of, 552 
keloid, 321-323 
Adenia, 557 
Adenoid cancer, 86 

of bowels. 650 
of liver, 727 
iEgophony, 366 
JEtiology. or causation, 21 

(See oho different diseases) 
Age, as cause of disease, 22 
Ague, 268 

brow, 274 
cachexia in, 275 
causation of, 268 
chronic, 275 
cold stage of, 271 



Ague, death in, 275 

definition of, 268 

diagnosis of, 273 

duration of, 275 

paroxysms of, 272 

enlargement of liver in, 276 
spleen in, 275, 276 

history of. 268 

hot stage of, 271 

incubation of, 270 

intermissions in, 272 

intermittent form of, 270 

malarious origin of, 269 

morbid anatomy of, 275 

non-contagiousness of, 268 

pathology of, 275 

pigment lormation in, 276 

quartan, 273 

quotidian, 273 

remittent form of. 273 

sweating stage of, 271 

symptoms and progress of, 270 

tertian, 273 

treatment of, 276 

unusual torms of, 274 
Air, impure, as cause of disease, 25 

passages, affection of in diphtheria, 203 
in syphilis, 245, 249 
casts of, 348 

in the pleura (see Pneumothorax), 447 
Albumen in urine, 760 

tests for, 761 
Albuminoid degeneration (see, Lardaceous De- 
generation), 88 
Albuminuria in diphtheria, 206 

in scarlet fever, 161 

(See also different renal diseases) 
Alcoholic poisoning, chronic, 568 
Alibert on keloid, 318 

on lupus erythematosus, 316 

on pemphigus, 310 
Alimentary canal, affection of, in hysteria, 
1013 

Alimentation in health, 35 
Allbutt, Dr., on choked disk, 958 

on hypertrophy of heart, 471 
Alopecia areata (vel Circumscripta) , 337 

causation of, 337 

description of, 337 

treatment of, 339 
Althaus, Dr., on electrolytic treatment of hy- 
datid cysts, 773 

on lead poisoning, 574 
Amnesia, 885, 887 
Amphoric breathing, 362 
bubble, 368 



1058 



INDEX. 



Amyloid degeneration (see Lardaceous), 88 
Amyotrophies spinales deuteropathiques (see 

Lateral Sclerosis), 928 
Anaemia, 560 

causation of, 560 

definition of, 560 

pathology of, 562 

symptoms and progress of, 560 

treatment o f , 562 

of brain, 1025 

symptoms of, 1025 
treatment of. 1027 
lymphatica, 557 
Anaemic dropsy, 104 
Anaesthesia, 870 
bulbar, 871 
cerebral, 871 
general, 871 
in chorea, 987 
in hysteria, 1012 
of nerves, 872 
spinal, 871 
unilateral, 871 
(See also various nervous diseases) 
Anasarca, 103 

in heart disease, 472 
in renal diseases, 768 
in scarlet fever. 161 
Andral on tubercle of nervous centres, 952 
Aneurism, 515 

causation of, 515 
contents of, 517 
effects of, on parts around, 518 
events of, 518 
form and size of, 515 
morbid anatomy of, 516 
symptoms and progress of, 518 
treatment of, 519 
walls of, 516 
Aneurisms, abdominal, 525 

morbid anatomy of, 525 
symptoms of, 525 
treatment of, 526 
cerebral (see Morbid Growths), 952, 956 

miliary, 964 
of heart, 499 

causation of, 499 
morbid anatomy of, 499 
symptoms of, 500 
thoracic, 520 

morbid anatomy of, 520 
symptoms of, 522 
treatment of, 524 
Angina pectoris, 506 

causation of. 506 
pathology of, 507 
symptoms and progress of, 507 
treatment of, 508 
Angioma, 68 

cavernous, 68 
simple, 68 
Anstie, Dr., on delirium tremens, 572 
on neuralgia, 1051 
on urea in urine in pneumonia, 109 
Anthrax (see Carbuncle), 288 
Aorta, aneurism of (see Aneurisms, Thoracic, 

and Abdominal), 520, 525 
Aortic valve disease, diagnosis of, 474,. 477 
effects of, on heart, 470 
obstructive, 467 
prognosis of, 480 
regurgitant, 468 



Aortic valve disease, treatment of, 482 
Aphasia, 885, 890 
in megrim, 1032 

in obstruction of cerebral arteries, 976 
Aphemia, 885, 886 
Aphonia, 343 

clericorum, 374, 376 

hysterical, 1013 
Aphtha (see Thrush), 584 
Apnoea, death from, 120 

Apoplectiform attacks in disseminated sclero- 
sis, 947 

Apoplexy (see Cerebral Anaemia and Conges- 
tion), 1027 
(see Cerebral Hemorrhage), 963 
(see also Morbid Growths. Sunstroke, and 

other Affections of the Brain) 
pulmonary (see Haemorrhage of Respira- 
tory Organs), 444 
Arteries, degeneration of, 513 
causation of, 513 
morbid anatomy of, 513 
symptoms of, 514 
dilatation of (see Aneurism), 515 
diseases of, 512 et seq. 
embolism of (.see Embolism), 528 
obstruction of, 528 
syphilitic disease of, 249 
thrombosis of (see Thrombosis), 528 
cerebral, obstruction of (see Cerebral 
Arteries, Obstruction of), 973 
Arteries, pulmonic, embolism of, 534 

thrombosis of, 534 
Arteritis (peri- and endo-), 512 
causation of, 512 
morbid anatomy of, 512 
symptoms of, 513 
Arthritis deformans (see Rheumatoid Arthrit- 
is), 825 
rheumatoid, 825 
Ascaris lumbricoides (see Round Worm, Com- 
mon), 652 
Ascites, 685 

causation of, 685 
morbid anatomy of, 685 
symptoms and progress of, 686 
treatment of, 688 
Asiatic cholera (see Epidemic Cholera), 223 
Asphyxia, death from, 120 
Asthenia, death from, 118 
Asthma, 450 ^ 
causation of, 451 
definition of, 450 
pathology of, 454 
symptoms and progress of, 451 
treatment of, 454 
Ataxy, locomotor (see Tabes Dorsalis), 932 
Atelectasis pulmonum (see Pulmonary Col- 
lapse), 442 
Atrophy, 87 

of heart, 466 

of kidney (see Hydronephrosis), 791 
progressive muscular (see Muscular At- 
rophy, Progressive), 925 
of spleen, 547 

yellow, of liver (see Malignant Jaundice), 
746 

Aura epileptica, 994 

Aural vertigo (see Meniere's Disease), 1035 
Auscultation, 353, 357 

abnormal, 361 

normal, 359 



INDEX 



1059 



Auscultation of breath, 359 
of voice, 360 

Autumnal catarrh, 456 
causation of, 456 
symptoms of, 457 
treatment of, 457 



Bacteria in diphtheria, 208 

in erysipelas, 284 

in gangrene, 95 

in pyaemia, 258 
Bakers' itch, 302 
Baldness in syphilis, 244 
Baly, Dr., on dysentery, 629 
Barbadoes leg {see Elephantiasis), 323 
Barker, Dr. T. A., on auscultation, 368 
Barlow, Dr., on urine in abdominal obstruc- 
tions, 682 
Barthez and Rilliet on noma, 587 
Basedow (or Graves's) disease, 504 
Bastian, Dr., on aphemia, 886 
Bazin on alopecia areata, 339 
Beale, Dr., on contagium, 137 

on molluscum contagiosum, 326 
Bedsores in nervous disease, 880 
Bell's paralysis {see Portio Dura, Paralysis of). 
1042 

Bennett, Dr. Hughes, on leucocythaemia, 72 
Bernard, M., on death from high temperature, 
111 

on cause of diabetes insipidus, 804 

on pathology of diabetes, 801 
Betz on anatomy of brain, 853 
Bichat on causes of death, 119 
Bile, composition of, 709 

ducts, obstruction of {see Hepatic Ducts. 

etc.). 741 
Bilharzia haematobia, 786 
Biliary concretions {see Gallstones), 736 
Bird, Dr. Golding, on uric acid calculi, 790 
Black induration of lung, 407 
Black vomit in yellow fever, 194 
Blackley, Mr., on hay-asthma, 455 
Bladder, gall, affections of, 742 
Bladder, urinary, dilatation of, 808 

diseases of, 807 

morbid growths of, 808 

inflammation of, 807 

tubercle of, 808 
Blebs, meaning of term, 281 
Blood, diseases of, 536 et seq. 
in urine, 762 

detection of, 762 
{see Hsematuria), 795 
Bloodvessels, in renal disease, 767 
Boeck on inoculation of syphilis, 253 
Boil, 288 

Bones, affection of, in mollities ossium, 844 
in pyaemia, 256 
in rickets, 838 
in syphilis, 245, 248 
Bothriocephalus latus, account of, 658 
symptoms of, 658 
treatment of, 658 
Bouchard on cerebral aneurisms, 964 
Bouchut on nitrate of silver in pertussis, 146 
Bowditch on causation of tubercle, 410 

on paracentesis thoracis, 404 
Bowels, cirrhosis of, 642 
treatment of, 642 
colloid cancer of, 648 



Bowels, compression and traetion of, 673 
constipation of, 670 
degenerations of, 667 
encephaloid cancer of, 640 
epithelioma of, 650 

haemorrhage from {see Haemorrhage from 

Stomach and Bowels), 689 
impaction of foreign bodies in, 675 
inflammation of {see. Enteritis), 609 
internal strangulation of, 674 
intussusception of, 677 
lymphadenoma of, 650 
malignant disease of (symptoms), 653 

treatment of, 654 
obstruction of, 670 et seq. 

constipation in, 681 

duration of life in, 682 

pain in, 680 

statistics of, 682 

treatment of, 682 

tumor in, 681 

urine in, 681 

vomiting in, 681 
sarcoma of, 650 
scirrhus of, 647 
stricture of, 671 
tubercle of, 642 

morbid anatomy of, 642 

symptoms and progress of, 645 

treatment of, 646 
ulceration of, 618 

causation of, 618 

consequences of, 621 

morbid anatomy of, 618 

symptoms and progress of, 622 

treatment of, 623 

varieties of, 618 
Brain, abscess of {see Encephalitis), 910 
anaemia of {see Anaemia of Brain), 1025 
congestion of {see. Congestion of Brain), 
1025 

diseases of, 891 et seq. 
dropsy of, 978 

haemorrhage of {see Cerebral Haemor- 
rhage), 963 
hydatids of, 955 

inflammation of {see Encephalitis), 910 
morbid growths of {see Morbid Growths 

of Brain), 952 
pyaemic affection of, 256 
softening of {see Obstruction of Cerebral 

Arteries), 973 
syphilitic affection of, 249, 953 
tubercle of, 900, 952 
Breast, affection of, in hysteria, 1015 

in mumps, 148 
Bretonneau on diphtheria, 200, 209 

on dysentery, 634 
Briancon on hydatid thrill, 731 
Bright, Dr., on case of Cardinal, 980 

on malignant jaundice, 748 
Bright's disease {see Nephritis) , 772 
Brinton, Dr., on gastric ulcer, 616 

on impaction of gallstones, 676 
on intestinal obstruction, 682 
on intussusception, 678 
on stricture of bowel, 672, 673 
on variations of urine in intestinal ob- 
struction, 682 
Broadbent, Dr., on co-ordination, 859 

on hemiplegia, 865 
Broca, M., on aphasia, 886, 889 



1060 



INDEX. 



Broca's convolution, 890 
Bronchial breathing, 361 

tubes, congestion of, 439 

dilatation of {see Bronchiectasis), 431 
diphtheritic affection of, 203 
inflammation of {see. Bronchitis), 378 
spasm of {see Asthma), 450' 
syphilitic affection of {see Syphilitic 
Disease of). 423 
Bronchiectasis, 431 
causation of, 431 
morbid anatomy of, 431 
symptoms and progress of, 433' 
treatment of, 434 
varieties of, 432 
Bronchitis, 378 
acute, 380 

bronchorrhoea in, 383 
capillary, 381 
causation of. 378 
chronic, 382 
dry, 382 

morbid anatomy of, 378 
plastic, 383 

symptoms and progress of, 380- 

treatment of, 383 
Bronchocele {see Goitre), 536 
Bronchophony, 361, 364 
Bronchorrhoea, 383 

Bronzed skin (.^Addison's Disease), 548 
Brown, Dr. Crichton, on treatment of epileptic 

paroxysm, 1003 
Brown induration of lung, 407 
Brown-Sequard on epileptic convulsions in 
guinea-pigs, 1002 

on paralysis of portio dura, 1044 

on reflex phenomena, 882 

on spinal epilepsy, 946 
Bruit, cardiac {see Murmur), 474 

de diable, 561 

de pot fele, 357 
Buboes in plague, 187 

Buchanan, Dr., on causation of phthisis, 410 
Budd, Dr. G, , on gastric ulcer, 616 
on hepatic abscess, 714. 722 
on pyaemia in dysentery, 631 
on pyrosis. 696 
Dr. W. , on origin of enteric fever, 212 
Bulama boil, 332 
Bullae, meaning of term, 281 

Willan's fourth order, 281 
Burton, Dr., on blue line in lead-poisoning, 
574 



Cachexia {see Dyscrasia), 43 
Caecum, ulceration of {see Typhlitis), 624 
Calcareous degeneration, 92 
Calculi, biliary {see Gallstones), 736 
pancreatic. 750 

urinary {see Urinary Concretions), 765. 
788 

Calenture Sunstroke), 1028 
Cancer {see Carcinoma), 81 
Cancroid {see Epithelioma), 85 
Capillary bronchitis, 382 
Carbuncle (boil), 288 

causation of, 288 

definition of, 288 

in plague, 187 

morbid anatomy of, 288 

symptoms of, 300 



Carbuncle, treatment of, 301 
Carcinoma, 81 

adenoid or tubular. 86 

colloid, 84 

encephaloid, 84 

epithelial, 85 

erectile or haematoid, 84 

lipomatous, 84 

melanotic, 84 

pultaceous, 84 

scirrhus, 83 

{See also Morbid Growths, and different 
organs) 

Cardiac diseases {see Heart, Diseases of), 457 
et seq. 

dropsy, 103 
Caries of vertebrae, 896 
Carter, Dr. V., on chyluria, 794 
Cartilaginous tumors, 65 
Caseation, 91 
Casts of air- passage, 348 

urinary tubules, 763 

blood, 763 

epithelial, 763 

fatty, 763 

granular, 763 

hyaline, 763 
Catalepsy, 1018 

treatment of, 1020 
Catarrh, 580 

causes of, 580 

epidemic (m; Influenza), 140 
morbid anatomy of, 580 
symptoms and progress of, 581 
treatment of, 583 
Causalgia, 879 

Causation of disease {see iEtiology), 21 

{See also different diseases) 
Causes of disease, chemical, 29 

endopathic, 28 

exciting, 21, 27 

exopathic. 28 

mechanical, 28 

predisposing, 21 , 22 

proximate, 21 

vital, 30 
fever, specific, 131 
Cavernous breathing, 362 

tumoi s of liver, 725 
Cavities, pulmonary, detection of, 369 
Cell districts, 34 

Cerebral anaemia {see Anaemia of Brain), 1025 
arteries, obstructions of, 973 
anaesthesia in, 976 
aphasia in, 976 
bedsores in, 977 . . 
causation of, 973 
hemiplegia in, 976 
morbid anatomy of, 973 
symptoms and progress of, 975 
treatment of, 977 
congestion {se? Congestion of Brain), 1025 
dropsy {see Hydrocephalus), 978 
hemorrhage, 963 
bedsores in, 970 
causation of, 963 
coma in, 967 
hemianaesthesia in, 969 
hemiplegia in, 969 
morbid anatomy of, 963 
muscular rigidity in, 971 
paralysis in, 968 



INDEX. , 1061 



Cerebral haemorrhage, recurrence of attacks 
of, 971 

symptoms and progress of, 966 
treatment of, 971 
Cerebro-spinal fever, 196 
causation of. 196 
causes of death in, 197 
complications of, 198 
definition of, 196 
history of, 196 
meningitis in, 199 
morbid anatomy of, 199 
mortality of, 199 
symptoms and progress of, 197 
treatment of, 199 
meningitis, epidemic (see Cerebro-spinal 

Fever). 196 
system, influence of diseases of, in caus- 
ing bedsores, 880 
eruptions, 879 
over nutrition, 875 
of bones, 877 
of joints. 877 
of muscles, 876 
of skin, 878 
of viscera, 881 
Cestoda, general account of, 655 
Chalk-stones {see Gout), 828 
Chancre, Hunterian. 244 

Charcot on affection of lateral columns of cord, 
867 

on affection of posterior columns of cord, 
867 

on artery of cerebral haemorrhage, 862 

on cerebral haemorrhage, 965 

on cerebral miliary aneurisms, 964 

on disseminated sclerosis, 941 et seq. 

on hysteria, 1010 et seq. 

on inflammation of nerve-cells, 917, 919, 
48 {note) 

on lateral sclerosis, 928 et seq. 

on locomotor ataxy, 932 et seq. 

on nutritive lesions in nervous diseases, 
877, 880 

on paralysis agitans, 948 et seq. 

on spinal haemorrhage, 912, 965 

on spinal paralysis in adults, 922 
Chauveau on contagium of cow-pox, 136 

on inoculation with putrid fluids, 45 

on inoculation of small-pox on lower ani- 
mals, 172 
Chemical causes of disease, 29 
Chest, contraction of, in disease, 352 

expansion of, in disease, 351 

form of, in disease. 351 

movement of, in disease, 352 

regions of, 343 
Cheyne, Dr., on hoarseness in children, 373 
Chicken-pox. 177 

causation of, 177 

definition of, 177 

duration of, 178 

incubation of, 177 

symptoms and progress of, 177 

treatment of, 178 
Chilblain, 293 

Chloasma (see Tinea Versicolor), 337 
Chlorosis (see Anaemia), 560 
Cholera, English, 703 

epidemic (see Epidemic Cholera), 223 

fungus (Hallier's), 225 

infantum, 703, 704 



Cholera, summer, 703 
Chondroma, 65 
Chorea, 984 

anaesthesia in, 987 

and heart disease, connection between, 
985 

and rheumatism, connection between, 
984 

causation of. 984 
definition of, 984 
emotional sensibility in, 988 
imbecility in, 988 
morbid anatomy of, 989 
paralvsis in, 987 
pathology of, 989 
symptoms and progress of, 985 
termination of, 988 
treatment of, 991 
Christison, Dr., on diagnosis of tetanus, 1023 
Chronic (refer to different diseases and in- 
flammations) 
Chylous urine (see Chyluria), 793 
Chyluria, 793 

causation of, 793 
pathology of, 794 
symptoms of, 793 
treatment of, 795 
Cicatrization, 57 
Circulation in health, 35 
Cirrhosis of bowels, 642 

symptoms of, 642 
of liver (see Hepatitis), 714 
of lungs, 405 

black induration in, 407 
brown induration in, 407 
causation of, 405 
definition of, 405 
gray induration in, 407 
in miners and others, 407 
morbid anatomy of, 405 
red induration in, 407 
symptoms of, 408 
treatment of. 409 ' 
of stomach, 642 
symptoms of, 642 
Clarke, Dr. Lockhart, on anatomy of cord, 
855 

on sclerosis, 917 

on tetanus, 1023 
Clavus in hysteria, 1011 
Climate as cause of disease, 26 
Clonic spasms, 873 
Cloudy swelling, 87 
Cobbold, Dr., on trichina spiralis, 665 
Cohn on microsphaera vaeciniae in cow-pox, 
137 

Cohnheim on inoculation of tubercle, 77 

on inflammation of cornea, 50 

on migration of leucocytes, 39 
Coindet on use of iodine in goitre, 541 
Cold as cause of disease, 25 

(see Catarrh). 580 
Colic, hepatic, 740 

lead (see Lead-poisoning), 573, 574 
Coliea pictonum (see Lead-poisoning), 573, 
574 

Colin on blood in glanders, 240 
Collapse, 116, 117 

circulation in, 117 

in cholera, 229 

of lungs (see Pulmonary Collapse), 442 
of lungs, in diphtheria, 209 



1062 



INDEX. 



Collapse, nervous functions in, 118 
symptoms of, 116 
temperature in, 117 
Colliers' phthisis, 407 
Colloid cancer. 84 

degeneration. 88 
Colon, inflammation of (see Dysentery), 628 

ulceration of (see Dysentery), 628 
Coloring matters in urine, 757 
Coma, death from. 121 
Compression of bowels, 673 
causation of, 717 
morbid anatomy of, 673 
symptoms and progress of, 674 
treatment of. 682 
Concretions, biliary (see Gallstones), 736 

urinary {see Urinary Concretions), 765, 
788 

Congestion, active and passive, 101 
of brain, 1025 

symptoms of, 1025 

treatment of, 1027 
of kidney, 782 

morbid anatomy of, 782 

symptoms of, 782 

treatment of, 782 
of larynx, trachea, and bronchial tubes, 
439 

of liver (see Hepatitis), 714 
of lungs, 439 

causation of, 439 
morbid anatomy of, 439 
symptoms of, 440 
treatment of, 440 
of pancreas, 750 
of respiratory organs, 439 
of spleen (see Spleen, Congestion of), 544 
Connective tissue, 33 

tumors, 61 
Consolidated lung, detection of, 369 
Constipation, 670 

causation of, 670 
morbid anatomy of, 670 
symptoms of. 670 
treatment of, 682 
Constitution, epidemic, 26 
Contagia, 132 

action of, within organism, 132 
are vegetable organisms, 137 
as causes of disease, 30 
behavior of, external to body, 134 
Chauveau and Sanderson's experiments 
on, 136 

discharge of. from system, 134 

with subsequent protection, 134 
fungus of cow-pox (Cohn), 137 
of enteric fever (Klein), 136 
of sheep-pox (Klein), 136 
of small-pox ( Weigert), 137 
mode of entrance of into organism, 133 

into organism, by atmosphere, 
133 

into organism, by food. 133 
into organism, by inoculation, 
133 

multiplication of, in organism, 133 
nature of. 135 

rod-like fungus of splenic fever, 136 
spirilla of relapsing fever (Obermeier), 
136 

Contagion in relation to fever, 132 
Contagious diseases, management of, 137 



Contractility, electric and Fa.radic, note in 

reference to, 920 
Contraction of limbs in disseminated sclerosis, 

946 

Convulsions, 872 
choreic, 873 
clonic, 873 
in chorea, 985 
in epilepsy, 994 

infantile (see Infantile Convulsions), 1005 
in hooping cough, 145 
in hysteria, 1010 
tonic, 873 
varieties of, 873 
Cord, spinal, dropsy of (see Hydrorhachis), 
978, 981 

haemorrhage of (see Spinal Haemor- 
rhage), 963 
inflammation of (see Meningitis and 

Myelitis), 900, 910 
morbid growths of (see Morbid Growths 

of Cord). 952 
sclerosis of (see Sclerosis), 917 et seq. 
Cornil and Ranvier on carcinoma, 82 

on classification of tumors, 62 

on cloudy swelling, 87 

on epithelioma, 86 

on psammoma, 81 

on pultaceous cancer, 84 

on rickets, 838 

on syphilitic disease of liver, 725 
on tubercle, 75 
Coronary arteries of heart, degeneration of, 

498 

Corona veneris, 245 

Corrigan, Sir D., on water-hammer pulse, 478 
Cough, 345 

varieties of, 346 
Coup de soleil (see Sunstroke), 1028 
Cow-pox (see also Vaccination), 171 

causation of, 171 

Chauveau's experiments, 172 

contagium of, 136 

definition of, 171 

relations of, with small-pox, 171 

symptoms and progress of, in cattle, 172 

symptoms and progress of, in man, 173 
Cracked-pot sound, 357 
Cramps in cholera, 229 
Craniotabes, 842 

symptoms of, 843 
Creighton, Dr., on vacuolation, etc., of liver- 
cells, 48 
Crepitation, 336 
Cretinism, 536, 539 

causation of, 539 

description of, 539 

pathology of, 539 

treatment of, 541 
Croup, membranous (see Diphtheria), 200 

spasmodic, 374, 376 
Cry, epileptic, 995 

hydrocephalic, 904 
Curling, Mr., on thyroid body, 541 
Cutaneous diseases, 278 et seq. 
Cyanosis, 508 

causation of, 508 

pathology of, 509 

symptoms and progress of, 509 

treatment of, 511 
Cyst-worms, general account of, 655 
Cysticercus cellulosse, 656 



INDEX 



1063 



Cysticercus cellulosae, of brain and cord {see 
Morbid Growths), 952, 955 

of heart, 495 

symptoms of. 658 

treatment of, 658 
Cysticercus tgenise mediocanellatae, 657 

symptoms of, 658 

treatment of, 658 
Cystin, 756 

calculi, 765 

Cystitis {see Inflammation of Urinary Blad- 
der), 807 
Cysts, 98 

by dilatation, 98 

by extravasation, 99 

by retention, 99 

by softening, 100 

of Fallopian tubes, 811 

of kidney, 778 

of liver, 725 

of ovary, 811 

of pancreas, 750 

of spleen, 547 



Dandy Fever {see Dengue), 191 
Danielssen and Boeck on leprosy, 265, 267 
Davis, Dr. H., on blisters in rheumatism, 823 
Davy on temperature, 106 
Death, 118 

of tissues {see Necrosis), 93 
from failure of circulation, 119 
of elimination, 120 
of nervous system, 121 
of nutrition, 119 
Decay in health, 36 
Degeneration, 87 
calcareous, 93 
colloid, 88 
fatty, 89 
in health, 36 
lardaceous, 88 
of kidney, 787 
of liver, 735 
of spleen, 547 
mucous, 88 

of arteries {see Arteries, Degeneration of) , 
513 

of bowels, 667 

of coronary arteries of heart, 498 

of heart {see Heart, Degeneration of), 495 

of stomach, 667 

of valves of heart {see Valves of Heart, 

Degeneration of), 497 
pigmentary, 91 
uratie, 92 

Delaroche and Berger on death from heat, 111 
Delirium, 891 

tremens. 568, 1026 
causation of, 568 
morbid anatomy of, 571 
pathology of, 571 
symptoms of, 569 
treatment of, 572 
Deltoid rheumatism. 1046 
treatment of, 1047 
Demodex folliculorum, 333 
Dengue, 191 

causation of, 191 
definition of, 191 
diagnosis of, 192 
history of, 191 



Dengue, symptoms and progress of, 191 

treatment of, 193 
Dentition, inflammation of gums in, 589 
Derangement, functional, 96, 100 

mechanical, 96 
Development in health, 35 
Dextrose in urine, 758 
Diabetes, 798 

causation of, 798 

insipidus {see Diuresis), 804 

morbid anatomy of, 801 

pathology of, 801 

symptoms and progress of, 798 

treatment of, 802 
Diarrhoea, 699 

causation of, 700 

infantile, 703 

pathology of, 700 

premonitory, of cholera, 228 

raw meat in, 707 

symptoms and progress of, 701 

treatment of, 706 
Dickinson, Dr., on alcohol and renal diseases, 
572 

on brain in diabetes, 801 

on chorea, 990 

on granular kidney, 778 

on lardaceous degeneration, 89 

on nephritis, 776 

on rickets, 841 

on tetanus, 1024 
Digestive organs, diseases of, 580 et seq. 
Dilatation of arteries {see Aneurism), 515 
of heart {see Aneurism of Heart), 499 
of lymphatics {see Lymphatic Vessels, 

Dilatation of), 559 
of oesophagus, 599 
of urinary bladder, 808 
of veins {see Varix), 527 
Diphtheria, 200 

affection of air-passages in, 203 

of deep tissues about neck in, 204 

of external parts in, 205 

of fauces and pharynx in, 202 

of kidneys in, 208 

of mouth in, 203 

of nose in, 205 

of oesophagus in, 203 
albuminuria in, 206 
bacteria in, 208 
causation of, 200 
causes of death in, 206, 207 
collapse of lungs in, 208 
definition of, 200 
duration of, 206 
history of, 200 
lobular pneumonia in, 208 
malignant, 204 
morbid anatomy of, 207 
mortality of, 206 
paralytic affections in, 206 
pathology of, 207 

structure of false membrane in, 208 

symptoms and progress of, 201 

tracheotomy in, 210 

treatment of, 209 

varieties of. 202 
Diphtherite (see Diphtheria), 200 
Disease, aetiology of, 21 

{See also the different diseases) 

change of type in, 26 

definition of, 17 



1064 



INDEX. 



Disease, physiological processes of, 37 

treatment of, 123 
Diseases of arteries, 512 et seq. 

of digestive organs. 580 et seq. 

of ductless glands, 536 et seq. 

of genito-urinary organs, 751 et seq. 

of the heart, 457 et seq. 

of the kidneys. 751 et seq. 

of the liver, 707 et seq. 

of the locoraotory organs, 816 et seq. 

of the lymphatics. 552 et seq. 

of the mouth, fauces, etc., 580 et seq. 

of the nervous system. 848 et seq. 

of the oesophagus, 596 et seq. 

of the pancreas, 749 et seq. 

of the pelvic organs, 807 et seq. 

of the respiratory organs, 341 et seq. 

of the skin, 278 et seq. 

of the spleen. 543 et seq. 

of the stomach, intestines, and perito- 
neum, 603 et seq. 

of Ihe suprarenal capsules, 548 

of the thyroid body, 536 

of the urinary bladder, 807 

of the uterus, Fallopian tubes, and ova- 
ries, 811 

of the vascular system, 457 et seq. 
of the veins, 526 et seq. 
Disinfection, 138 

Disseminated Sclerosis {see Sclerosis, Dissemi- 
nated). 941 
Districts, cell, 34 

Dittrich on diffusion of tubercles, 77 
Diuresis, 804 

causation of, 804 

in hysteria, 1082 

morbid anatomy of, 805 

symptoms and progress of, 804 

treatment of, 805 
Dochmius duodenalis, 664 
Donkin, Dr., on diabetes, 803 
Double consciousness, 1020 

treatment of, 1020 
Double vision in oculo motor paralysis, 1039 
Drink, as cause of disease, 24 
Dropped hand (sr 
Dropsy, 103 

abdominal (s 

anaemic, 104 

anasarca, 103 

cardiac, 103 

cerebral (see. Hydrocephalus 
general, 103 
local. 104 
of larynx, 441 
of lungs. 441 

of respiratory organs, 441 

causation of, 440 

morbid anatomy of, 440 

symptoms of. 441 

treatment of, 442 
pericardial, 502 
pleural, 441 
pulmonic, 103 
renal, 193 
in scarlet fever, 160 
spinal (set Hydrorhachis) , 978 
Drunkard's liver, 718 
Duchenne on deltoid rheumatism, 1046 
on diphtherial paralysis, 207 
on dropped hand, 575 
on functional spasm, 1049 



Lead-poisoning), 573, 575 
? Ascites), 685 

978 



Duchenne on glosso-labio-laryngeal palsy, 938 
et seq. 

on infantile paralysis, 922 

on locomotor ataxy, 936 et seq. 

on neuralgia, 1055 

on paralysis of musculo-spiral nerve, 1046 

of portio dura, 1043 et seq. 
on progressive muscular atrophy, 925 et 
seq. 

on pseudo-bypertrophic paralysis, 846 et 
seq. 

on spinal paralysis (of adults), 922 
(general), 923 
Duchenne (fils) on infantile paralysis, 919 
Duckworth, Dr., on tinea tonsurans. 335 
Ductless glands, diseases of, 536 et seq. 
Ducts, hepatic, inflammation of, 716, 719 
obstruction of, 741 
pancreatic, dilatation of, 750 
obstruction of, 750 
Duodenal ulcers, 624 

causation of, 624 
symptoms of. 624 
treatment of, 624 
Dupre, Dr., on elimination of alcohol. 571 
Dupuy on localization of functions of brain, 
852 

Dura mater, inflammation of, 891 
causation of, 891 
morbid anatomy of, 891 
morbid anatomy of (cerebral), 891 
morbid anatomy of (chronic), 892 
morbid anatomy of (spinal). 892 
symptoms and progress of, 893 
symptoms and progress of acute 

(cerebral), 893 
symptoms and progress of acute 

(spinal), 896 
symptoms and progress of chronic 

(cerebral), 894 
symptoms and progress of chronic 

(spinal). 898 
symptoms and progress of (in ver- 
tebral carie*). 896 
treatment of, 899 
Dysesthesia, 874 
Dyscrasia, primary, 43 

secondary, 44 
Dysentery, 628 

causation of, 628 
definition of, 628 
morbid anatomy of, 629 
sequelae of, 633 

symptoms and progress of, 631 

terminations of. 632 

treatment of, 633 
Dyspepsia, 691 

appetite in, 694 

causation of. 692 

eructation in, 694 

flatulence in, 694 

nausea in, 695 

pain and uneasiness in, 694 

pyrosis in, 696 

sickness in, 695 

symptoms of. 693 

treatment of, 697 
Dysphagia, 600 
Dyspnoea, 345 

Ear, disease of, causing meningitis, etc., 893, 
911 



INDEX. 



1065 



Ecchondrosis, 65 

Ecchymosis, meaning of term, 279 
Echinococcus, description of, 659 
Eclampsia. 992, 1004, 1026 

causation of, 1004 

definition of, 104 

symptoms and progress of, 1004 

treatment of, 1005 
Ecstasy. 1018, 1019 

description of, 1019 

treatment of, 1020 
Ecthyma (see Impetigo), 304 
Eczema, 300 

acute, 302 

causation of, 300, 302 
chronic, 302 
description of, 300 

identity of, with lichen and strophulus, 

300 

impetiginodes, 302 

lichen agrius, a variety of, 302 

circumscriptus, a variety of, 302 

simplex, a variety of, 302 
ruhrum, 302 

strophulus confertus, a variety of, 302 
intertinctus, a variety of, 302 
volaticus. u variety of, 302 
treatment of, 303 
Electric contractility of paralyzed muscles, 
869 

note in reference to, 920 
sensibility of paralyzed muscles, 869 
Electrolytic treatment of hydatids, 733 
Elephantiasis, 327 

affection of lymphatics in, 324 
Arabum (see Elephantiasis) 
causation of, 323 
description of. 323 
lymphangiectodes, 325, 560 
affection of lymphatics in, 325 
causation of, 325 
description of, 325 
filariae in blood in, 325 
treatment of, 325 
Elephas (see Elephantiasis) 
Elimination, 128 

Elliotson, Dr., on hay-asthma, 455 

on iron in paralysis agitans, 951 
Embolism, 528, 530 
and chorea, 989 
causation of, 530 
consequences of, 532 
morbid anatomy of, 530 
of cerebral arteries (see Obstruction cf 

Cerebral Arteries), 973 
portal, 531 
pulmonic, 531 
pyaemic, 257 
symptoms of. 532 
treatment of, 535 
Emotional disturbance, pathology of, 890 

sensibility in chorea, 988 
Emphysema of lungs, 434 
causation of, 434 
interlobular, 434 
morbid anatomy of, 434 
symptoms and progress of, 438 
treatment of, 439 
vesicular, 434 
varieties of, 434 
Emprosthotonos, 1023 
Empyema, 398, 401 



Empyema, consequences of, 398, 402 
Encephalitis, 910 

causation of, 910 

morbid anatomy of, 910 

symptoms and progress of, 912 

treatment of, 916 
Encephaloid cancer, 84 

(See. also Morbid Growths) 
Enchondroma, 65 

Endemic, in relation to fevers, 131 
Endoarteritis (see Arteritis), 512 
Endocarditis, 489 
causation of, 489 
morbid anatomy of, 489 
prognosis of, 491 
symptoms and progress of, 490 
treatment of. 491 
Endopa thic causes of disease, 28 
Enostoses. 66 
Enteric fever, 210 

causation of, 210 
causes of death in, 218 
complications of, 217 
contagium of, 1 37 

decomposing faeces in relation to, 211 

definition of, 210 

diagnosis of, 219 

history of, 210 

intestinal disease in, 219 

intestinal haemorrhage in, 217 

intestinal perforation in, 217 

mesenteric gland affection in, 221 

morbid anatomy of, 219 

mortality in, 219 

peritonitis in, 217 

pulmonary affection in, 218 

spleen, enlargement of, in, 221 

symptoms and progress of, 213 

treatment of, 221 

varieties of, 216 
Enteritis. 609 

catarrhal. 609 

causation of, 609 

morbid anatomy of, 609 

symptoms and progress of, 609 
chronic, 610 

causation of, 610 

morbid anatomy of, 610 

symptoms of, 610 
pellicular, 609 

causation of, 609 

morbid anatomy of, 609 

symptoms of, 610 
phlegmonous, 610 

causation of, 610 

morbid anatomy of, 610 

symptoms and progress of, 611 
treatment of, 613 
Entozoa (see Parasites and Parasitic Diseases, 

or Morbid Growths of Different Organs) 
Epidemic catarrh (see Influenza) , 140 

cerebro- spinal meningitis (see Cerebro- 
spinal Fever), 196 
cholera, 223 

algide stage in, 229 

causation of, 223, 228 

collapse in, 229 

death in, 229, 231 

definition of, 223 

diagnosis of, 232 

epidemic extension of, 223 

history of, 223 



1066 



INDEX. 



Epidemic cholera, incubation of, 228 

injection of saline fluids in, 236 

morbid anatomy of, 232 

mortality of, 232 

outbreak in India, 223 

pathology of, 232 

premonitory diarrhoea in, 228 

Radcliffe's, Mr., investigations, 227 

reaction in, 230 

relation of. to diarrhoea, 231 

Sanderson's, Dr., experiments as to 
transmission of, 227 

Schmidt's solution for injection in, 235 

Snow's, Dr., investigations, 225 

specific fungus in, 224 

symptoms and progress of, 228 

telluric and atmospheric causes of, 224 

Thiersch, experiments as to transmis- 
sion of, 227 

treatment of, 234 

varieties of, 231 
constitution, 26 
diseases, management of, 137 
in relation to fevers, 131 
roseola, 153 

causation of, 153 

definition of, 153 

diagnosis of, 154 

incubation of, 153 

symptoms and progress of, 153 
Epilepsia gravior, 996 

mitior, 996 
Epilepsy, 992 

causation of, 992 
definition of, 992 
diagnosis of, 999 
feigned, 1001 
morbid anatomy of, 1001 
pathology of, 1001 

spinal, in disseminated sclerosis, 946 
symptoms and progress of, 993 
treatment of, 1003 
Epileptic attack, description of, 993 
aura in, 994 

clonic convulsions in, 995 
coma in, 994 
cry in, 995 

exciting causes of, 999 

recurrence of, 998 

tonic convulsions in, 994 

unconsciousness in, 994 
mania, 999 
state, 998 
vertigo, 996 

varieties of, 996 
Epileptiform neuralgia (see Tic Douloureux), 
1053 

Epiphora in paralysis of the portio dura, 1043 
Epithelial tissues, 33 
Epithelioma, 85 

(See also Morbid Growths) 
Equinia (see Glanders), 239 
Erysipelas, 283 

a specific fever, 284 

bacteria in, 284 

causation of, 283 

contagiousness of, 283 

definition of, 283 

erratic, 285 

hypertrophy in, 286 

idiopathic, 283 

in small-pox, 167 



Erysipelas, larynx, involvement of, in, 285 
meninges, involvement of, in, 285 
morbid anatomy of, 284 
phlegmonous, 287 
pneumonia in. 286 

serous membranes, extension of, to, 286 
simple, 287 

symptoms and progress of, 286 
traumatic, 283 
treatment of, 287 
varieties of, 287 
veins, extension of, to, 286 
Erythema, 290 

causation of, 291 
circinatum, 292 

(See also Tinea Tonsurans), 333 
description of, 291 
fugax, 293 
gyratum, 292 

identity of, with roseola, urticaria, and 

pityriasis, 290 
in nervous diseases, 878 
in rheumatism, 820 
intertrigo, 291 
iris, 292 
lEeve, 291 
marginatum, 292 
multiforme, 292 
nodosum, 293 
papulatura, 292 

pityriasis capitis, a form of, 292 

simplex, a form of, 292 
purpura urticans, a variety of, 293 
roseola, a variety of, 293 

autumnalis, a variety of, 293 
simplex, 291 
tuberculatum, 293 
treatment of, 295 
urticaria, a variety of, 294 
Essential paralysis (see Paralysis, Spinal In- 
fantile), 918 
Etiology of disease (see Etiology) 
Eulenburg on pulse in tabes dorsalis, 934 
Exanthem, or exanthema, meaning of term, 
279 

Exanthemata, Willan's third order, 280 
Exciting causes, 21, 27 
Excretion in health, 35 
Exopathic causes of disease, 28 
Exophthalmic goitre (see Graves's Disease), 503 
Exostosis, 66 
Expectoration, 347 
bloody, 347 
fetid, 348 
nummulated, 347 
of foreign bodies, 348 
plastic (casts of tubes), 348 
pneumonic, 347 
purulent, 348 
varieties of, 347 
Exudation, inflammatory, 53 
Eyes, affection of, in syphilis, 245 

in disseminated sclerosis, 944 

in meningitis, 906 

in morbid growths of the brain, 958 

in oculo-motor paralysis, 1036 

in renal disease, 768 

in tabes dorsalis, 934 

Facial neuralgia (see Tic Douloureux) 

palsy (see Paralysis of the Portio Dura), 
1042 



INDEX. 



1067 



Fagge, Dr. H., on compression of bowel, 674 
and Durham on electrolytic treatment of 

hydatid cysts, 733 
on scleroderma, 322 
on thyroid body, 541 
on xanthoma, 319 
Fallopian tubes, dilatation of, 811 

diseases of, 809 
Falret on epileptic mania, 999 
False membrane in diphtheria, 208 
Famine fever (see Relapsing Fever), 187 
Faradic contractility {note in reference to), 
920 

Farcy (see Glanders), 239 

buds, 240 
Fatty degeneration, 89 
of heart, 496 

of liver {see Liver, Fatty), 734 
growth of heart, 495 

symptoms of, 495 
tumors, 63 
Fauces, gangrene of, 587, 588 
causation of, 588 
symptoms and progress of, 588 
treatment of, 588 
syphilitic disease of, 595 
tubercle of, 595 
Favus {see Tinea Favosa), 335 
Febris rubra {see Scarlet Fever), 154 
Fehling's test for sugar, 759 
Ferrier, Dr., on irritation of semicircular 
canals, 1034 
on functions of cerebral convolutions, 852 
Fever, 105 

blood in, 110 

causes of high temperature in, 111 
cerebro-spinal {see Cerebro-spinal Fever), 

196 
crisis in, 110 
dandy {see Dengue), 191 
enteric (see Enteric Fever), 210 
famine {see Relapsing Fever), 187 
hay {see Hay- Asthma), 455 
heat or thermic, 1030 
hectic, 113 
-f- intermittent (see Ague), 268, 270 
lysis in, 110 

relapsing {see Relapsing Fever), 187 
~V remittent (see Ague), 268, 274 
rheumatic (see Rheumatism). 816 
scarlet (see Scarlet Fever), 154 
symptoms of, 108 

referable to alimentary canal in, 109 
to heart in, 108 
to lungs in, 109 
to nervous system in, 110 
to skin in, 110 
temperature in, 108 
thermometer in, 112 
-f—- typhoid {see Enteric Fever), 210 
typhus (see Typhus Fever), 178 
urine in, 1 09 
waste of tissue in, 110 
Fevers, prophylactic treatment of, 137 
specific, 131 et seq. 
specific causes of, 131 
Fibroid degeneration of heart, 496 
Fibroma, 63 
Fibrous tumors, 63 

Fifth nerve, neuralgia of {see Tic Doulou- 
reux), 1053 
paralysis of, 1040 



Fifth nerve, paralysis of, causation of, 1040 
symptoms and diagnosis of, 1041 
treatment of, 1042 
ulceration of cornea in, 1041 

Filarise in blood, 325, 795 

Flax-dressers' phthisis, 407 

Flint, Dr. A., detection of pulmonary cavities, 
369 

Flint, Dr. A., Jr., on eholesterin in bile, 710 
Flourens on use of semicircular canals, 1034 
Food, as cause of disease, 24 
Foreign bodies, impaction of, in bowels {see 

Impaction, etc.), 675 
Forster, Mr. Cooper, on hydrophobia, 238 
Fox, Dr. Wilson, on diarrhoea in dyspepsia, 
696 

on inoculation of tubercle, 77 
on origin of cysts, 99 
Fremitus, vocal, 352 

Frerichs on conversion of urea into ammonia, 
767 

on fatty liver, 735 
on jaundice, 711, 712, 745 
on malignant jaundice, 748 
on pyrosis, 696 
on situation of liver, 735 
Friction sounds, pericardial, 474 

pleural, 369 
Friedreich, on hepatic pulsation, 1056 
Functional derangements, 96, 100 
collapse, 116 
congestion, 101 
dropsy. 103 
fever, 105 
hectic, 113 
syncope, 116 
typhoid condition, 114 
spasm and paralysis (local), 1047 
causation of, 1047 
definition of, 1047 
pathology of, 1049 
symptoms of, 1047 
treatment of, 1050 
Furfura, meaning of term, 282 
Furunculus (see Carbuncle), 288 



Gairdner, Dr., on asthma, 454 

on delirium tremens, 572 

on prsesystolic murmur, 480 

on pulmonary collapse, 443 
Galabin, Dr., on pulse trace, 462 
Gall-bladder, dilatation of, 742, 743 

mucous cyst of, 741 

shrivelling of, 742 
ducts (see Liver, Ducts of), 716, 741 
stones, 736 

causation of, 737 

chemical constitution of, 738 

consequences of, 738 

impaction of, in bowels (see Impaction 
of Foreign Bodies in Bowels), 675 

morbid anatomy of, 737 

size and shape of, 737 

symptoms and progress of, 739 

treatment of, 741 
Gangrene, 55, 93 
in leprosy, 266 

of fauces (see Fauces, Gangrene of), 588 
of lung, in pneumonia, 389 
Garrod, Dr., on gout, 828 et seq. 
on lead-poisoning, 574 



1068 



INDEX. 



Garrod, Dr., on rheumatism, 823 
on rheumatoid arthritis, 828 
on scurvy. 565 
Gastric {see Stomach) 
Gastritis, 604 

causation of, 604 

morbid anatomy of.. 605 

symptoms and progress of. 605 
of acute, 606 
of chronic, 607 
of mild, 606 

treatment of, 608 
Gastrodynia, 694, 698 
Gee, Dr., on scarlet fever, 158 
Generalization of morbid growths, 40 
Genito urinary organs, diseases of, 751 et seq. 
Gingivitis {see Gums, Inflammation of), 589 
Glaisher, Mr., on cholera mist, 224 
Glanders. 239 

causation of, 239 

chronic form of, 240 

definition of, 239 

diagnosis of, 240 

farcy, 240 

history of, 239 

incubation of, 239 

morbid anatomy of, 240 

results of, 240 

symptoms and progress of, 239 
treatment of, 241 
tubercles of (farcy buds), 240 
Glandular laryngitis. 372 
Glioma, 65 

of brain and cord {see Morbid Growths), 
952. 954 
Globus hystericus. 1010 
Glossitis, 589 

causation of, 589 
symptoms and progress of, 590 
treatment of, 590 
Glosso-labio-laryngeal palsy, 938 
causation of, 938 
definition of, 938 
morbid anatomy of, 939 
symptoms and progress of, 939 
treatment of, 941 
Glossy skin. 879 
Glucose in urine, 758 
Glue-like tumor, 64 
Glvcosuria {see Diabetes), 798 
Goitre, 536 

causation of, 536 

exophthalmic {see Graves's Disease), 503 
morbid anatomy of, 537 
submaxillary, 539 
substernal, 539 

symptoms and progress of, 538 

treatment of, 541 

varieties of, 537 
Gonorrhoeal rheumatism, 817, 821 
Goodeve, Dr., on raw meat in diarrhoea, 707 
Gout, 828 

causation of, 828 

chalk-stone (or tophi) in, 830 

definition of, 828 

morbid anatomy of, 829 

pathology of, 834 

symptoms and progress of, 830 

treatment of, 835 
Gr'afe, von, on Graves's disease, 506 
Granular degeneration of heart, 496 
Granulation, 56 



Granuloma, 73 

Grape-sugar in urine, 758 

Gravel {spe Urinary Concretions), 788 

Graves on chorea, 984 

Graves's disease, 503 

causation of, 504 

definition of, 504 

enlargement of thyroid in, 505 

morbid anatomy of, 504 

palpitation in, 503 

protrusion of eyeballs in, 505 

symptoms and progress of, 504 

treatment of, 506 
Green-sickness {see Anaemia and Chlorosis), 
560 

Greenfield, Dr , on adenoid cancer {note), 86 

on tubercle of spinal meninges, 902 
Greenhow, Dr. EL, on cirrhosis of lungs, 407 

on paracentesis of hydatid cysts, 732 
Gregory, Dr., on statistics of small-pox inocu- 
lation, 171 
Gray hepatization of lung, 387. 388 

induration of lung, 407 
Griffin, Messrs., on spinal irritation, 1015 
Grocers' itch {s?e Eczema), 302 
Growth in health, 35 

morbid {see Morbid Growth), 38 
Growth, morbid {see Tumors, 61 et seq.; see 

also morbid growths of different organs) 
Guerin on rickets in puppies, 837 
Gull, Sir W., on factitious urticaria, 295 
on hydrorbachis. 983 
on vitiligoidea, 319 
and Dr. Sutton on abscess of brain, 
911 

and Dr. Sutton on hyaline-fibroid 
change of vessels. 767 
Gummata, 78 

{See Syphilis), 241 ; see also Syphilitic 
Diseases, or morbid growths of different 
organs. 

Gums, inflammation of, 589 
Gurgling, 367 



Habits as causes of diseases, 24 
Haeruatemesis {see Haemorrhage from Stomach, 

etc.), 689 
Hsematoidin crystals, 91 
Haamatinuria, 797 
Hematuria, 762, 795 
causation of, 795 
paroxysmal, 796 
causation of, 796 
pathology of, 797 
symptoms and progress of, 796 
treatment of, 798 
symptoms of, 795 
treatment of, 796 
Hsemoptysis, 348 

{See also Haemorrhage of Respiratory Or- 
gans), 444 
Haemorrhage {see Haemorrhage), 444 
Haldane, Dr., on carbonate of lime calculi, 
766 

Halford, Sir H., on catarrh, 583 
Hall, Dr. Marshall, on epilepsy, 1002 
Hallier on cholera-fungi, 225 
Hare, Dr.. on treatment of hysteria, 1017 
Harley, Dr. George, on biliary acids in urine, 
711,712,757 
on ox-gall in jaundice, 745 



INDEX. 



1069 



Ilarley, Dr. George, on paroxysmal haematu- 
ria, 796 

Dr. John, on bilharzia in urine, 787 
Hassall, Dr., on lead-poisoning, 574 
Haut mal (see Epilepsy), 999 
Hay-asthma, or hay-fever, 455 
causation of, 455 
definition of, 455 
symptoms and progress of, 455 
treatment of, 455 
Headache, 883 

as a symptom of granular kidney, 779 
in megrim, 1030 
varieties of, 883 
Health, physiological processes in, 32 
Hearing, affection of, in megrim, 1032 

in Meniere's disease, 1035 
Heart, anatomical relations of, 457 

aneurism of (see Aneurism of Heart), 499 
atrophy of, 466 
causes of, 469 
diagnosis of, 478 
prognosis of, 478 
treatment of, 478 
degeneration of, 495 
causation of, 495 
fatty, 496 
fibroid, 496 
granular, 469 
morbid anatomy of, 495 
symptoms of, 497 
treatment of, 499 
diagnosis, prognosis, and treatment of 

specific lesions of, 475 et seq. 
diagnostic indications of derangements 
of, 472 

alterations in area of cardiac dul- 
ness, 473 
in form of praecordial region, 472 
diastolic murmurs. 474 
direct murmurs, 474 
endocardial murmurs, 474 
increased resistance, 473 
pericardial friction, 474 
presystolic murmur, 475 
pulsation, 473 
regurgitant murmurs, 474 
systolic murmurs, 474 
thrill, 473 

venous murmurs, 475 
dilatation of, 470 
cause of, 470 
diagnosis of, 477 
prognosis of, 477 
treatment of, 477 
dimensions of, 457 
disease in chorea, 985 
diseases of, 457 et seq. 
displacement of, 465 
effects of derangement of, 469 

in causing dilatation, 470 
in causing hypertrophy, 470 
on organism, 471 
fatty growth of (see Fatty Growth of 

Heart), 495 
form of, in disease, 471 
functional derangements of, 468 
motor, 468 
sensory, 469 
hypertrophy of, cause of, 466, 469 
diagnosis of, 477 
in renal disease, 767 



Heart, hypertrophy of, prognosis of, 477 
treatment of, 477 
inflammation of (see Myo- and Endo-car- 

ditis), 488, 489 
malformations of (see Malformations of 

Heart), 510 
malignant diseases of, 494 
mechanical derangements of, 465 

from affections of contents, 468 
from affections of valves, 466 
from affections of walls, 466 
from external affections, 465 
morbid growths of, 493 
neuralgia of (see Angina Pectoris), 506 
parasitic disease of (see Parasites of 

Heart), 495 
pathology of, 464 et seq. 
physiology of, 460 
action of, 460 
sounds of, 461 
pyaemic affection of, 356 
rupture of, 500 

causation of, 500 
morbid anatomy of, 500 
symptoms and progress of, 501 
syphilitic disease of, 249 

(See also Syphilis of Heart), 493 
thrombosis of, 534 
tubercle of, 493 
Heat, as cause of disease, 25 
Heat fever, 1030 
Hebra on acarus scabiei, 329 
on acne rosacea, 314 
on eczema, 303 
on elephantiasis, 325 
on erysipelas, 284, 288 
on erythema, 292 
on lichen ruber, 320 
on pityriasis rubra, 298 
on prurigo, 340 
on psoriasis, 296 
Hectic fever, 113 

symptoms of, 113 
Helmerich's ointment for scabies, 331 
Helmholtz on hay-asthma, 455 
on muscles of eyeball, 1038 
Hemiansesthesia, 871 

in cerebral haemorrhage, 970 
in hysteria, 1012 

in obstruction of cerebral arteries, 976 
Hemicrania (see Megrim), 1030 
Hemiplegia, 864 

in cerebral haemorrhage, 969 

in hysteria, 1012 

in morbid growths of brain, 957 

in obstruction of cerebral arteries, 976 
Haemorrhage from bowels in enteric fever, 
217 

cerebral (see Cerebral Haemorrhage), 963 
of cord (see Spinal Haemorrhage), 963 
into pericardium, 501 
of respiratory organs, 348, 444 

causation of, 444 

morbid anatomy of, 444 

symptoms and progress of, 446 

treatment of., 447 

varieties of, 445 
from stomach and bowels, 689 

causation of, 689 

symptoms and progress of, 689 

treatment of, 690 
from urinary organs (see Haematuria), 795 



1070 



INDEX. 



Hepatic diseases (see Diseases of the Liver), 
707 et seq. 
pulsation in heart disease, 1056 
Hepatization, gray, of lungs, 387, 388, 389 
red, of lungs, 387, 388, 389 
white, of lungs (see Syphilitic Disease of 
Respiratory Organs), 423 
Hepatitis, 714 

causation of, 714 
morbid anatomy of, 715 
of cirrhosis, 717 
of congestion, 715 
of inflammation of ducts, 716 
of simple, 715 
of suppurative, 716 
symptoms of, 718 
of cirrhosis, 721 
of congestion, 718 
of inflammation of ducts, 719 
of simple, 718 
of suppurative, 719 
treatment of, 722 
Heredity as cause of disease, 23 
Herpes, 306 

causation of, 306 
circinatus, 308, 334 
description of, 306 
in pneumonia, 390 
iris, 308 

relation of, to erythema, 306 

simplex, 308 

treatment of, 309 

varieties of, 307 

zoster, 307 
Heterologous tumors, 62 
Heuter on bacteria in diphtheria, 208 
Hob-nail liver, 718 
Homologous tumors, 62 
Hooping-cough, 143 

causation of, 143 

complications of, 145 

convulsions in, 145 

definition of, 143 

duration of, 145 

incubation of, 143 

morbid anatomy of, 145 

mortality of, 145 

symptoms and progress of, 143 

treatment of, 146 
Hunter, John, on identity of gonorrhoea and 

syphilis, 242 
Hutchinson, Dr., on spirometry, 370 

Mr. J., on syphilis, 251 
on xanthoma, 320 
Hydatid thrill, 731 
Hydatids, 659 

of brain and cord (see Morbid Growths), 
952. 955 

of heart, 495 

of kidney (see Kidney, Hydatids of), 786 

of liver {see Liver, Hydatids of), 730 

of lungs, 430 
Hydrocephalic cry, 904 
Hydrocephalocele, 979 
Hydrocephalus, 978 

acute (see Meningitis), 900 

causation of, 978 

chronic, 979 

morbid anatomy of, 978 

symptoms and progress of, 981 

treatment of, 983 
Hydroineningocele. 979 



Hydronephrosis, 791 

causation of, 791 

morbid anatomy of, 791 

symptoms and progress of, 792 

treatment of, 792 
Hydropericardium, 502 
Hydrophobia, 236 

causation of, 236 

definition of, 236 

in dogs, 238 

duration of, 238 

excitement, stage of, in, 237 

history of, 236 

incubation of, 237 

melancholic stage of, 237 

morbid anatomy of, 238 

mortality of, 238 

sublingual vesicles in, 239 

symptoms and progress of, 236 

treatment of, 238 
Hydrorhachis, 978 

causation of, 978 

external (spina bifida), 979 

internal, 981 

morbid anatomy of, 978 

symptoms and progress of, 983 

treatment of, 983 
Hydrothorax (see Dropsy of Respiratory Or- 
gans), 440 
Hygiene, 123 
Hygienic treatment, 123 
Hypersesthesia, 874 

in hysteria, 1011 
Hyperplasia, 46 
Hyperpyrexia, 108 
Hypertrophy, 46 

of heart (see Heart, Hypertrophy of), 466, 
470, 477 

of spleen (s^ Spleen, Hypertrophy of) , 545 
Hysteria, 1007 

alimentary canal, affection of, in, 1082 

anaesthesia in, 1012 

aphonia in, 1013 

causation of, 1007 

clavus in, 1011 

convulsions in, 1009, 1012 

definition of, 1007 

diagnosis of, 1015 

diuresis in, 1014 

ether, in the diagnosis of, 1016 

globus hystericus in, 1010 

hemiplegia in, 1012 

hyperesthesia in, 1010 

joints, affections of, in, 1015 

larynx, affections of, in, 1013 

mammae, affections of, in, 1015 

mental condition in, 1008 

ovaries, condition of, in, 1011 

paralysis in, 1012 

paraplegia in, 1012 

pathology of, 1016 

reproductive organs, affections of, in, 1014 
spinal irritation in, 1015 
spine, affections of, in, 1015 
suppression of urine in, 1014 
symptoms and progress of, 1008 
treatment of, 1017 

urinary organs, affections of, in, 1014 



Ichthyosis, 298 
cornea, 299 



INDEX. . 



1071 



Ichthyosis cornea, treatment of, 300 
simplex, 299 

treatment of, 299 
Icterus (see Jaundice) 
Impaction of foreign bodies in bowel, 675 
causation of, 675 
morbid anatomy of, 675 
symptoms and progress of, 676 
treatment of, 682 
Impetigo, 304 

causation of, 304 
description of, 304 
erysipelatodes, 305 
figurata, 304 
porrigo larvalis, 305 
scabida, 305 
sparsa, 304 
sycosis, 305 
treatment of, 305 
Impure air, as cause of disease, 26 
Indican in urine, 757 
Indigestion (see Dyspepsia), 691 
Indigo in urine, 757 
Induration, black, of lungs, 407 
brown, of lungs, 407 
gray, of lungs, 407 
red, of lungs, 407 
Infantile convulsions, 992, 1005 
causation of, 1005 
definition of, 1005 
symptoms and progress of, 1005 
treatment of, 1006 
paralysis (see Paralysis, Spinal Infantile), 
918 

Infection, in relation to fevers, 132 
Inflammation, general pathology of, 47 
abscess in, 54 

cause of change of size in vessels, in, 52 

varying rates of blood flow in, 52 
cicatrization after, 57 
constitutional effects of, 58 
destructive processes in, 55 
extravascular processes in, 48 
exudation in, 53 
gangrene in, 55 
granulation in, 56 
ichor in, 55 
in cartilage, 48 
in cornea, 49 
in mesentery, 49 
in vascular tissues, 51 
migration of leucocytes in, 51 
organization in, 56 
pus-cells in, 53 

redness, swelling, heat and pain in, 47 
repair after, 57 
sanies in, 55 
spread of, 58 
stasis of blood in, 51 
suppuration in, 53 
ulceration in, 55 
varieties of, 59 
vascular processes in, 50 
vessels, dilatation of, in, 51 
Inflammation, local 

of arteries (see Arteritis), 512 

of bowels (see Enteritis), 609 

of brain (see Encephalitis), 910 

of bronchial tubes (see Bronchitis), 378 

of cord (see Myelitis), 910 

of dura mater, 891 

of endocardium (see Endocarditis), 489 



Inflammation of gums (see Gums, Inflamma- 
tion of), 589 
of kidney (see Nephritis and Pyelitis), 769, 
772 

of larynx (see Laryngitis;, 370 

of liver (see Hepatitis), 714 

of lungs (see Pneumonia), 385 
chronic (see Cirrhosis), 405 

of lymphatics (see Lymphatics, Inflamma- 
tion of), 553 

of meninges (see Meningitis), 900 

of mouth, fauces, etc. (see Catarrh. Thrush, 
Stomatitis, Noma). 580, 584, 586, 587 

of muscular walls of heart (see Myocar- 
ditis), 488 

of nervous centres, chronic (see Sclerosis), 
917, 

of oesophagus (see (Esophagus, Inflamma- 
tion of), 597 
of oesophagus, ulcerative, 597 
of ovaries, 809 
of pancreas, 750 

of pericardium (see Pericarditis) , 483 
of peritoneum (see Peritonitis), 635 
of pleura (see Pleurisy), 395 
of spleen (see Spleen, Inflammation of), 
543 

of stomach (see Gastritis), 604 

of thyroid body, 536 

of tongue (see Glossitis), 589 

of tonsils (see Quinsy), 591 

of trachea (see Tracheitis), 377 

of urinary bladder, 807 

of uterus, 809 

of veins (see Phlebitis), 526 
Influenza, 140 

causation of, 140 

complications of, 141 

definition of, 140 

diagnosis of. 142 

duration of. 141 

history of, 140 

incubation of, 140 

morbid anatomy of, 142 

mortality of, 142 

relations of, with cholera, 140 

symptoms and progress of, 140 

treatment of, 142 
Innocent, meaning of, as applied to tumors, 45 
Inoculation, for small-pox, 163, 171 

of specific fevers, 132 
Insolatio (see Sunstroke), 1028 
Insular sclerosis (see Sclerosis, Disseminated), 
941 

Intermittent fever (see Ague), 268, 270 
Intestinal glands, affection of, in cholera, 232 
in enteric fever, 217 
haemorrhage in enteric fever, 217 
worms (see Parasitic Affections of the Di- 
gestive Organs), 655 
Intestines, diseases of (see Stomach, Intestines, 

and Peritoneum, Diseases of), 603 et seq. 
Intussusception, 677 
causation of, 677 
morbid anatomy of, 677 
symptoms and progress of, 679 
treatment of, 682 
Invagination (see Intussusception) 
Irritability of paralyzed muscles, 870 
Ischuria renalis (see Urine, Suppression of), 
805 

Itch (see Scabies), 328 



1072 



INDEX. 



Jaccoud on reflex action, 958 
Jackson, Dr. H , on chorea, 989 
on convulsions, 874 
on headache, 883 
on pupiis, inequality of, 970 
on retinal vessels in epilepsy, 1001 
Jaundice, 710 

bilious toxaemia in, 714 
connected with gallstones, 740 
in ague, 275 
in heart disease, 472 
in hepatitis, 718 et seq. 
in morbid growths of liver, 728 
in pneumonia, 392 
in pyaemia, 259 
in relapsing fever, 189 
in yellow fever, 194 
malignant. 746 
causation of, 746 
morbid anatomy of, 748 
symptoms and progress of, 746 
treatment of, 749 
obstructive. 743 
pathology of, 710 
symptoms of, 712 
without obstruction, 745 
causation of, 745 
morbid anatomy of, 745 
symptoms of, 746 
treatment of, 746 
Jenner, Dr. E. , on vaccination, 174 

Sir W., on rickets, 837, 839 
Johnson. Dr. George, on cholera, 234 
on enteric fever, 222 
on renal disease, 767 
on sunstroke, 1029 
Joints, affection of. in gout (see Gout), 828 
in hysteria, 1015 
in nervous diseases, 877 
in pyaemia, 256 

in rheumatism (see Rheumatism), 
816 

in rheumatoid arthritis (see Rheuma- 
toid Arthritis), 825 
in rickets (see Rickets), 837 
in syphilis. 245. 248 
in tabes dorsalis, 934 
in typhus, 184 
Jurgensen on temperature, 106 



Kelis (see Keloid), 318 
Keloid, 318 

Addison's (see Scleroderma), 321 
causation of, 318 
description of, 318 
false, 319 
treatment of, 319 
Keratitis, in congenital syphilis, 251 
Kidney, affection of, in diphtheria. 208 
in gout, 830 
in hysteria, 1015 
in lead poisoning, 574 
in nervous diseases, 881 
in pyaemia, 256 
in scarlet fever, 158, 161 
in syphilis, 250 
atrophy of (see Hydronephrosis), 791 
Bilharzia haematobia in, 786 

treatment of, 787 
carcinoma of (see Morbid Growths of), 
784 



Kidney, congestion of (see Nephritis, 772). 782 
contracted granular (see Nephritis, 772), 
777 

cystic (see Nephritis, 772), 778 
diseases of, 751 et seq. 
fatty (see Nephritis, 772), 776 
general considerations in relation to dis- 
eases of, 751 
hydatids of, 786 

treatment of, 786 
inflammation of (see Nephritis), 772 
lardaceous degeneration of, 787 
causation of, 787 
morbid anatomy of, 787 
symptoms and progress of, 787 
treatment of, 788 
lyraphadenoma of (see Morbid Growths 

of), 784 
misplaced (see Movable) , 792 
morbid growths of, 784 
anatomy of, 784 
symptoms and progress of, 785 
treatment of, 786 
movable or floating, 792 
symptoms of, 793 
treatment of, 793 
parasitic affections of, 786 
smooth white (see Nephritis, 772), 776 
suppuration of (see Pyelitis, 769, and Ne- 
phritis, 772) 
syphilitic disease of. 784 
Kirkes, Dr., on embolism as cause of chorea, 
989 

Klein, Dr., or contagium of enteric fever, 137 
on contagion of sheep-pox, 136 
on tubercle, 78 
Kb'ster, on epithelioma. 86 
Krishaber on paralysis of larynx, 449 
Kuchenmeister. on acarus folliculorum, 333 

on pedicnli, 327 
Kuhne, on biliary acids in urine, 712 



Laennec on tubercle, 73, 77 
Lancereaux on pachymeningitis, 895 

on syphilis, 243 
Lardaceous degeneration, 88 

of kidney (see Kidney, Lardaceous De- 
generation of), 787 
of liver (.see Liver, Lardaceous Degener- 
ation of), 735 
of spleen (see Spleen, Lardaceous De- 
generation of) , 547 
Laryngeal phthisis, 375 

(See also Tubercle of Respiratory Organs, 

409) 
syphilis, 375 
Laryngismus stridulus, 374, 1006 
Laryngitis, 370 
acute. 372 

aphonia clericorum, 374 
causation of, 370 
chronic, 374 
complications of, 373 
cough in, 373 
dyspnoea in, 372 
morbid anatomy of, 371 
phthisical, 375 
spasmodic attacks in. 374 
symptoms and progress of, 372 
syphilitic, 375 
treatment of, 375 



INDEX. 



1073 



Laryngitis, voice in, 373 

Laryngoscope, 349 

Larynx, anatomical relations of, 341 

congestion of (see Congestion of Respira- 
tory Organs), 439 
Larynx, hysterical affection of, 1013 

inflammation of (see Laryngitis), 370 
morbid growths of (see Morbid Growths 

of Respiratory Organs). 425 
oedema of (see Dropsy of Respiratory Or- 
gans), 440 

paralysis of (see Paralytic Affections of 

Larynx), 448 
spasm of, 450 
syphilitic disease of, 375 

(See also Syphilitic Disease of Respira- 
tory Organs), 423 
tubercle of, 375, 409 
Lateral sclerosis (see Sclerosis, Lateral), 928 
Latham, Dr., on megrim, 1033 
Laycock, Dr., on delirium tremens, 572 
Lead colic, 574 
palsy, 575 

poisoning, chronic, 573 

from use of, as a cosmetic, 574 
causation of, 573 
colic in, 574 
dropped hand in, 575 
morbid anatomy and pathology of, 
576 

symptoms and progress of, 574 
treatment of, 577 
Lee, Mr. H.. on syphilis, 242, 243 
Leontiasis (see Leprosy), 265 
Lepra (see Psoriasis), 296 
Leprosy, 262 

anaesthetic, 266 

a specific disease, 264 

causation of, 262 

causes of death in, 266 

contagiousness of, 263 

definition of, 262 

duration of, 266 

gangrene in, 266 

history of, 262 

internal organs, affection of, in, 267 
leontiasis, 265 
macular, 264 

morbid anatomy and pathology of, 266 

nerve affection in, 267 

symptoms and progress of, 264 

treatment of, 267 

tubercles, development of, in, 267 

tubercular, 264 
Leptus autumnalis, 332 
Letzerich on inoculation of diphtheria, 201 
Leucin, 756 

Leuckart, on trichina spiralis. 665 
Leucocytes, migration of, 39, 51 
Leucocytheernia, 73, 557 

pathology and morbid anatomy of, 557 

symptoms and progress of, 558 

treatment of, 558 
Leucophlegmasia, 559 
Leukeemia, 73, 557 

pseudo, 73 
Lewis, Dr., on filariae in blood, 325, 795 
Lice (see Phthiriasis), 327 
Lichen (see Eczema), 300 

circinatus, 334 

ruber, 320 

treatment of, 321 



Lientery, 702 

Limbs, contractions of, in disseminated scle- 
rosis, 946 
Lipoma. 63 

Liveing, Dr., on leprosy, 264 

on megrim, 1033 
Liver, abscess of (see Hepatitis), 714 
adenoid cancer of, 727 
anatomical relations of, 707 
carcinoma of, 727 
cavernous tumors of, 725 
cirrhosis of (see Hepatitis), 714 
congestion of (see Hepatitis), 715 
cysts of, 725 
diseases of, 707 et seq. 
drunkard's, 717 
fatty, 734 

causation of. 734 

morbid anatomy of, 734 

symptoms of, 735 

treatment of, 735 
hob-nail, 718 
hydatids of, 730 

morbid anatomy of, 730 

symptoms and progress of, 730 

treatment of, 732 
in ague, 276 

inflammation of (see Hepatitis), 714 
jaundice in disease of (see Jaundice), 710 
lardaceous, 735 
causation of, 735 
morbid anatomy of, 735 
symptoms of, 736 
treatment of, 736 
ly mphadenoma of, 727 
malignant growths of, 726 

morbid anatomy of, 726 

symptoms and progress of, 727 

treatment of, 729 
melanotic sarcoma of, 727 
morbid growths of, 723 et seq. 
parasitic disease of, 730 
pathology (general) of, 710 
physiology (general) of, 708 
pulsation of, in heart disease, 1056 
pyaemic affection of, 256 
sarcoma of, 727 
syphilitic affection of, 724 

morbid anatomy of, 249, 724 

symptoms of, 725 

treatment of, 725 
tubercle of, 723 

yellow atrophy of (see Malignant Jaun- 
dice), 746 

Liver-ducts, inflammation of (see Hepatitis), 
714 

obstruction of, 741 

biliary toxaemia in, 744 
causation of, 741 

dilatation as a consequence of, 742 

jaundice in, 743 

morbid anatomy of, 742 

perforation as a consequence of, 742 

symptoms and progress of, 743 

treatment of, 744 
Local paralyses, 1036 
Lockjaw (see Tetanus), 1020 
Locomotion, organs of, diseases of, 816 et 
seq. 

Locomotor ataxy (see Tabes Dorsalis), 932 
Lousiness (see Phthiriasis), 327 
Lumbago, 818 



1074 



INDEX. 



Lungs, anatomical relations of, 341 
in cholera, 232 

cirrhosis of (see Cirrhosis of Lungs), 405 

collapse of (see Pulmonary Collapse), 442 

congestion of (see Congestion of Respira- 
tory Organs), 439 

emphysema of (see Emphysema), 434 

haemorrhage from (see Haemorrhage of 
Respiratory Organs), 444 

hydatids of (see Parasitic Disease of 
Lungs), 430 

inflammation of (see Pneumonia), 385 

morbid growths of (see Morbid Growths 
of Respiratory Organs), 425 

oedema of (see Dropsy of Respiratory Or- 
gans), 440 

pyaetnic affection of, 255 

syphilitic disease of, 249 

(See also Syphilitic Diseases of Respira- 
tory Organs), 423 

tubercle of (see Tubercle of Respiratory 
Organs), 409 
Lupus, 316 

causation of, 316 

description of, 316 

erythematosus, 316 

exedens, 317 

non-exedens, 317 

pustular, 317 

treatment of, 318 

tubercular, 316 
Luys and Voisin on epilepsy, 1002 
Lymphadenoma, 69 

of abdominal lymphatics, 650 

of bowels, 650 

of kidney (see Kidney, Morbid Growths 

of), 784 

of liver (see Liver, Lymphadenoma of), 
727 

of peritoneum, 650 
of stomach, 650 
Lymphangioma, 69 

Lymphatic glands of abdomen, malignant 
disease of, 654 
tubercle of, 643 
in glanders, affection of, 241 
in leprosy, affection of, 267 
in plague, enlargement of, 187 
in syphilis, affection of, 244, 249 
scrofulous, 70 
tumors, 68 

vessels, obstruction and dilatation of, 

559 

treatment of, 560 
Lymphatics, diseases of, 552 et seq. 
in elephantiasis, 324 
in elephantiasis lymphangiectodes, 
325 

inflammation of, 553 
causation of, 553 
morbid anatomy of, 553 
symptoms and progress of, 553 
treatment of, 554 
morbid growths of, 554 
in mediastinum, 555 
symptoms and progress of, 555 
treatment of, 557 
tubercle of. 554 

morbid anatomy of, 554 
symptoms and progress of, 554 
treatment of, 554 
Lymphoma, 68 



Mackenzie, Dr. M., on chronic laryngitis, 

374 

on laryngeal phthisis, 375 
on paralysis of larynx, 449 
on stricture of oesophagus, 603 
on syphilitic disease of larynx, 423 
Maclean, Dr., on dengue, 275 

on hepatic abscess, 716 
Macula, meaning of term, 279 
Maculae, Willan's eighth order, 279 
Magnan on delirium tremens, 571 
Mahomed, Dr., on blood in urine, 762 

on urine in scarlet fever, 768 
Maintenance in health, 26 
Malaria, 30, 270 
Malformation of heart, 510 
causation of, 510 
morbid anatomy of, 510 
symptoms and progress of, 511 
treatment of, 511 
Malignant, as applied to tumors, 45 

cholera (see Epidemic Cholera), 223 
diphtheria, 204 
growths (see Morbid Growths) 
of bowels, 647 
of brain and cord, 952 
of heart and pericardium, 494 
of kidney, 784 
of larynx, 425 
of lungs and pleurae, 426 
of lymphatic glands, 554, 647 
of mediastinum, 555 
of mouth, fauces, etc., 595 
of oesophagus, 600 
of ovaries, 814 
of pancreas, 750 
of peritoneum, 646 
of spleen, 546 
of stomach, 646 
of suprarenal capsules, 552 
of thyroid body, 536 
of uterus, 814 
jaundice, 746 
scarlet fever. 160 
small-pox, 168 
Marutnae. affection of, in hysteria, 1015 

in mumps, 148 
Mania epileptica, 999 
Marochetti on hydrophobia. 238 
Marson, Mr., on small-pox. 164 et seq. 
Measles, 149 

causation of, 149 
causes of death in, 152 
complications and sequela) of, 151 
definition of, 149 
duration of, 151 
incubation of, 149 
morbid anatomy of, 152 
symptoms and progress of, 149 
treatment of, 152 
varieties of, 151 
in adults, 152 
Mechanical causes of disease, 28 
derangements, 96 
compression, 97 
contraction, 97 
dilatation, 98 
displacement, 96 
impaction, 97 

rupture and extravasation, 100 
Mediastinal tumors. 555 

symptoms and progress of, 556 



INDEX. 



1075 



Medulla oblongata (see Bulbar Paralysis and 

Bulbar Anaesthesia), 865, 871 
Megrim. 1030 

aphasia in, 1032 

causation of, 1030 

definition of, 1030 

drowsiness in, 1032 

duration of, 1033 

headache in, 1031 

hearing, affection of, in, 1032 

mental affections in, 1032 

paralysis in, 1032 

pathology of, 1033 

sight, affection of, in, 1031 

symptoms and progress of, 1031 

treatment of, 1033 
Meigs, Dr. John F., on cholera infantum, 
704 

Melaena (see Haemorrhage of Stomach and 

Bowels), 689 
Melansemia in ague, 275 
Melanuric bilious fever, 797 
Melasma Addisonii (see Addison's Disease), 

548 

Melassez on Alopecia areata (note), 339 
Melsens on treatment of lead-poisoning, 577 
Membranous croup (see Diphtheria), 200 
Meniere's disease, 1034 

causation of, 1034 

definition of, 1034 

pathology of, 1 034 

symptoms and progress of, 1035 

treatment of, 1036 
Meningeal haemorrhage (see Cerebral Haemor- 
rhage), 963 
Meningitis, 99, 900 
causation of, 900 

cerebro-spinal (see Cerebro-spinal Fever), 
196 

morbid anatomy of, 900 
cerebral, 900 
spinal, 902 
symptoms and progress of, 902 
cerebral, 902 
spinal, 902 
treatment of, 908 
tubercular, 900, 901 

symptoms and progress of, 902 
treatment of, 908 
Mental disturbance, pathology of, 872 
Mercurial poisoning, chronic, 578 
causation of, 578 
morbid anatomy of, 580 
symptoms and progress of, 578 
treatment of, 580 
Mercurialism, 578 

Mesenteric glands, affection of, in enteric 

fever, 221 
Metallic breathing, 362 

tinkling, 363 
Metritis, 809 

Meynert on anatomy of brain and cord, 853 et 
seq. 

Miasm, as cause of ague, 269 
Michaud on vertebral caries, 892 
Microsporon Audouini, 339 

furfur, 337 
Migraine (see Megrim), 1030 
Migration of leucocytes, 39, 51 
Miliaria, 306 

Mill-stone grinders' phthisis, 407 
Miners' phthisis, 407 



Mitchell, Dr. S. W., on causalgia and glossy 

skin, 879 
Mitral valve disease, 467 

diagnosis, 474, 479 
effects of on heart, 470 
obstructive, 467 
prognosis of, 535 
regurgitant, 467 
treatment of, 482 
Moissonet on puncture of hydatid cysts, 732 
Mollities ossium, 844 

causation of, 844 
definition of, 844 
morbid anatomy of, 844 
pathology of, 844 
symptoms and progress of, 845 
treatment of, 845 
Molluscum contagiosum, 326 
causation of. 326 
description of, 326 
treatment of, 326 
Montague, Lady M. W., on inoculation of 

small-pox, 163 
Moore's test for sugar in urine, 758 
Morbid growth, 38 

dyscrasia primary in, 43 

secondary in, 44 
generalization of, 40 
limitation of to certain tissues, 42 
local spread of, 39 
of cells, 38 
Morbid growths of bowels, 653 
of brain, 952 

hemiplegia in, 957 
intellectual and emotional disor- 
ders in, 958 
local anaesthesia in, 958 
local paralysis in. 957 
morbid anatomy of, 952 
obstruction of the venous sinuses 
in, 959 

symptoms and progress of, 956 
treatment of, 962 
vertigo in, 956 
vomiting in, 956 
of digestive organs, 646 
malignant, 647 

morbid anatomy of, 647 
symptoms and progress of, 651 
treatment of, 654 
non-malignant, 646 
polypoid, 646 
villous, 647 
of heart and pericardium, 493 
of kidney (see Kidney, Morbid Growths 
of), 784 

of larynx, symptoms and progress of, 
425 

treatment of, 426 
of liver, 723 

malignant, 726 

morbid anatomy of, 726 

non-malignant, 725 

symptoms and progress of, 727 

treatment of, 729 
of lungs and pleuree, 426 

malignant and non-malignant, 426 

symptoms and progress of, 428 

treatment of, 430 
of lymphatics (see Lymphatics, Morbid 

Growths of), 554 
of mouth, fauces, etc., 595 



1076 



INDEX. 



Morbid growths of oesophagus (see (Esopha- 
gus, Morbid Growths of), 598 
of pancreas, 750 
of peritoneum, 654 
of respirator}' organs, 425 
of spinal cord, 952 

morbid anatomy of, 952 
symptoms and progress of, 961 
treatment of, 962 
of spleen (see Spleen, Morbid Growths 

of), 546 
of stomach, 652 
of suprarenal capsules, 552 
of thyroid body, 536 
of uiinary bladder, 808 
of uterus and ovaries, 810 
Morbilli (see Measles), 14 9 
Morbus coinitialis (see Epilepsy), 992 
Morphoea (see Scleroderma), 321 
Mortification {see Gangrene) 
Mosquitoes, 332 

Mouth, affection of. in diphtheria, 203 

diseases of, 580 et seq. 

syphilitic disease of, 596 

tubercle of. 596 
Moxon, Dr., on insular sclerosis, 942 
Mucous degeneration, 88 

tubercles in syphilis, 245 

tumors, 65 
Muller, J., on classification of tumors, 61 
Multiple sclerosis (see Sclerosis, Disseminated), 

941 
Mumps, 147 

causation of, 147 

complications and sequelae of, 147 
definition of, 147 
diagnosis of, 147 
incubation of, 147 
inflammation of breast in, 148 

of testicle in, 14S 
morbid anatomy of, 148 
symptoms and progress of, 147 
treatment of, 148 
Murchison, Dr., on biliary acids in urine, 711 
on cholesterin in urine, 764 
on enteric fever, 211 et seq^ 
on gout, cause of, 834 
on hydatid cysts, puncture of, 732 
on jaundice from constipation, 711 
on liver, functional disturbance of, 710 

physiology of, 708 
on reabsorption of bile, 746 
on typhus, 180 et seq.. 
Murmurs, endocardial, 474 

aortic obstructive, 478 

regurgitant, 478 
mechanism of, 474 
mitral obstructive, 479 

regurgitant, 479 
preesystolic, 480 
pulmonic obstructive, 479 

regurgitant, 480 
quality of, 474 
tricuspid obstructive, 48fr 
regurgitant, 480 
pericardial, 474 
venous, 475 
Muscles, condition of, in paralysis, 868 
contractility, 869 
electro-sensibility, 869 
irritability, 869 
nutrition, 869 



Muscles, reflex action of in paralysis, 870 
tone, 868 

rigidity of, in cerebral haemorrhage, 971 
in paralysis agitans, 950 
in tetanus, 1021 
Muscular atrophy, progressive, 925 
causation of, 925 
definition of, 925 
morbid anatomy of, 925 
symptoms and progress of, 925 
treatment of, 927 
tumors, 67 
Musculo-spiral nerve, paralysis of, 1046 

treatment of, 1047 
Myelitis, 910 

causation of, 910 
morbid anatomy of, 910 
symptoms and progress of, 912 
treatment of, 916 
Myeloid tumors, 81 
Myocarditis, 488 

causation of, 4S8 
morbid anatomy of, 488 
Myoma, 67 

of ovaries. 810 
of uterus, 810 
Myxoma, 64 

of brain and cord (see Morbid Growths of 

Brain and Cord), 952, 954 
cystic, 64 

enchondromatous, 64 
erectile, 64 
lipomatous, 64 

Nasmatoda, general account of, 661 
Nails, affection of, in favus, 336 
in tinea tonsurans, 334 
Nausea in dyspepsia, 695 
Necrosis, 93 
Nephritis, 772 

acute (general), 724 

morbid anatomy of, 724 
symptoms and progress of, 724 
treatment of, 775 
causation of, 772 
chronic (general), 776 

morbid anatomy of, 776 
symptoms and progress of, 779 
treatment of, 781 
circumscribed, 772 
congested kidney, 782 

morbid anatomy of, 782 
symptoms of, 782 
treatment of, 782 
contracted granular kidney, 777 
cystic kidney, 778 
desquamative, 774 
fatty kidney, 776 
smooth white kidney, 776 
suppurative, 772 

morbid anatomy of, 772 
symptoms of, 773 
treatment of, 774 
Nerve-lesions, central consequences of, 882 

reflex consequences of, 882 
Nerves, affection of, in leprosy, 267 
Nervous diseases, ascending lesions in, 881 
collateral lesions in, 881 
descending lesions in, 881 
influence of, over nutrition, 875 
functions in health, 35 



INDEX. 



1077 



Nervous system, anatomy and physiology of, 

848 

arachnoid cavity, 849 
arteries, 861 

cerebellum and peduncles, 853 
cerebral hemispheres, 850 
cerebro spinal nerves, 855 
convolutions, 851 
functions of surface of brain, 852 
ganglia at base of brain, 853 
medulla oblongata, 855 
membranes of brain and cord, 848 
motor and sensory functions, 858 
pia mater, 849 
spinal cord, 854 
sulci, 850 

sympathetic system, 860 

veins, 863 

ventricles, 849 
diseases of, 848 et seq. 

introduction to, 848 
pathology of, 863 

amnesia. 885 

anaesthesia, 870 

aphasia, 885 

aphemia, 885 

convulsions and spasm, 872 
emotional disturbance, 890 
headache. 883 
mental disturbance, 890 
nutritive lesions, 875 
paralysis and paresis, 864 
vertigo, 884 
Nervous tumors, neuroma, 66 
Nettle-rash (see Urticaria), 294 
Neuralgia, 1050 

anaesthesia in, 1052 
causation of. 1050 
convulsive movements in, 1052 
definition of, 1 050 

dilatation of vessels in connection with, 
1052 

epileptiform (see Tic Douloureux), 1053 
in zona, 307 

nutritive lesions in, 1052. 

of heart (see Angina Pectoris), 506 

painful spots in, 1052 

symptoms and progress of, 1051 

treatment of, 1054 
Neuritis, optic, 906, 958 
Niemeyer on diffusion of tubercle, 77 

on ulcer of duodenum, 624 
Nodes, syphilitic, 245. 248 
Noli me tangere (see Lupus), 316 
Noma, 587 

causation of, 587 

morbid anatomy of, 587 

symptoms and progress of, 587 

treatment of, 588 
Nose, affection of. in diphtheria, 205 
in glanders, 2H9 
in syphilis, 250, 251 
Nummulated sputum, 347 
Nutmeg liver (see Cirrhosis), 717 
Nutrition of paralyzed muscles, 869 

influence of nervous diseases over, 875 

of bones, influence of nervous diseases 
over, 877 

of joints, influence of nervous diseases 
over, 877 

of muscles, influence of nervous diseases 
over, 876 



Nutrition of skin, influence of nervous diseases 
over, 878 

of viscera, influence of nervous diseases 
over, 881 
Nutritive lesions in neuralgia, 1052 
Nystagmus in disseminated sclerosis, 944 



Obermeier on contagium of relapsing fever, 
136 

Obstruction of arteries. 528 

of bowels (see Bowels, Obstruction of), 670 

of cerebral arteries (see Cerebral Arteries, 
Obstruction of). 973 

of hepatic ducts (see Hepatic Ducts, Ob- 
struction of) , 741 

of lymphatic vessels (see Lymphatic Ves- 
sels, Obstruction of), 559 

of stomach (see Stomach, Obstruction of), 
667 

of urinary passages (see Urine, Suppres- 
sion of), 805 
of veins. 528 
Occlusion (see Obstruction) 
Occupation, as cause of disease, 24 
Oculo- motor nerves, paralysis of, 1036 
causation of, 1036 
symptoms and diagnosis of, 1037 
treatment of, 1040 
Odorous matters in urine, 758 
<Edema (see, Dropsy), 103 

of larynx (see. Dropsy of Respiratory 

Organs), 440 
of lungs (see Dropsy of Respiratory Or- 
gans), 440 

Oertel on the cause of diphtheria, 201, 208 
(Esophagus, anatomical relations of, 596 
diseases of. 596 et seq. 
chronic affections of, 597 

auscultation in. 602 

dysphagia in. 600 

obstruction in, 600 

symptoms of, 600 

treatment of, 602 
dilatation of, 599 
diphtherial affection of, 203 
implication of. from without, 599 
inflammation of. 597 

causation of, 597 

symptoms of, 597 
morbid growths of, 598 
paralysis of. 600 
spasm of. 600 
ulceration of, 597 
Oidium albicans in thrush, 585 
Oophoritis, 809 

Ophthalmia in relapsing fever, 190 

in small-pox. 167 

in trifacial palsy, 1041 
Opisthotonos, 1023 

Ord, Dr., on temperature in pseudo-hypertro- 
phic paralysis, 847 
on gout, 8H5 
Orfila, L., on lead in system, 576 
Organization in inflammation, 56 
Orthopnoea (see Dyspnoea), 345 
Osseous tumors, 66 

Osteo-malacia (see Mollities Ossiutn), 844 
Osteomata, 66 

compact, 66 

ivory, 66 

spongy, 66 



1078 



INDEX. 



Otitis (see Inflammation of Dura Mater and 

Encephalitis), 891, 910 
Ovarian dropsy (see Ovaries, Cysts of), 811 
Ovaries, cysts of, 811 

symptoms and progress of, 813 
treatment of, 814 
diseases of, 809 
inflammation of, 809 
malignant disease of, 814 

symptoms of, 815 
myomata of. 810 
tubercle of, 810 
Ovary, effects of pressure on, in hysteria, 1011, 
1018 

hyperesthesia of, in hysteria, 1011 
Oxalate of lime, 760 
calculi, 765 

Oxyuris vermicularis (see Threadworm), 663 
Ozcena, 594 

causation of, 594 

symptoms of, 594 

treatment of, 595 



Pachydermia (see Elephantiasis), 323 
Pachymeningitis (see Dura Mater, Inflamma- 
tion of), 891 

cerebral, 893. 895 

spinal, 892, 898 
Paget, Mr., on myeloid tumors, 81 

on recurrent fibroid tumors, 81 
Pain (see Hyperesthesia), 874 
Paltnelle, as cause of ague, 269 
Palpitation, 503 

Palsy, glosso-labio-laryngeal (see Glosso-labio 
laryngeal Palsy), 938 
lead (see Lead-Poisoning, Chronic), 573 
wasting (see Muscular Atrophy, Progres- 
sive). 925 

(See also Paresis and Paralysis) 
Pancreas, abscess of, 750 
calculi of. 750 
cysts of, 750 
diseases of, 749 et seq. 

introduction to, 749 
ducts of, dilatation of, 750 

obstruction of, 750 
hyperemia of. 750 
inflammation of, 750 
morbid growths of, 750 
treatment of diseases of, 750 
Papula, meaning of term, 280 
Papule, Willan's first order, 280 
Paracentesis abdominis, 688, 723, 732 

thoracis, 403 
Paralysis, meaning of term, 864 
agitans, 948 

causation of, 948 
definition of, 948 
morbid anatomy of, 948 
symptoms and progress of, 949 
treatment of, 951 
bulbar, pathology of, 865 
in cerebral hemorrhage, 968 
cerebral, pathology of, 864 
in chorea, 987 

condition of muscles in (see Muscles, Con- 
dition of, etc.), 868 

in diphtheria, 206 

in disseminated sclerosis, 945 

essential (see Paralysis, Spinal Infantile), 
918 



Paralysis of fifth nerve (see Fifth Pair, Paraly- 
sis of), 1040 
general, pathology of, 864 
in hysteria, 1012 

infantile (see Paralysis, Spinal Infantile), 
918 

laryngeal, 448 
general, 449 

involving recurrent laryngeal, 448 
superior laryngeal, 449 

treatment of, 450 

unilateral, 449 
local, 1037 

functional, 1047 

in tumors of brain, 957 
in megrim, 1032 
of musculo-spiral nerve, 1046 

treatment of, 1047 
of nerves, pathology of, 868 
of oculo-motor nerves (see Oculo-Motor 

Nerves, Paralysis of), 1036 
of esophagus, 600 
pathology of, 863 

of portio dura (see Portio Dura, Paralysis 

of), 1042 
pseudo hypertrophic, 846 
causation of, 846 
definition of, 846 
morbid anatomy of, 846 
pathology of, 848 
symptoms and progress of, 846 
treatment of, 848 
spinal, adult, 922 
general, 923 

causation of, 923 
definition of. 923 
morbid anatomy of, 923 
symptoms and progress of, 923 
treatment of, 924 
infantile, 918 
causation of, 918 
definition of, 9 18 
morbid anatomy of, 919 
symptoms and progress of, 919 
treatment of, 921 
pathology of. 866 
of spinal nerves (see Spinal Nerves, Pa- 
ralysis of), 1045 
unilateral, pathology of, 946 
Paraplegia in hysteria, 1012 
pathology of, 866 
(See also various diseases of spinal cord) 
Parasites as causes of disease, 30 
Parasitic affections of brain, 955 

of digestive organs, 655 et seq. 
of heart, 495 
of kidney, 786 
of liver, 730 

of respiratory organs, 430 

morbid anatomy of, 430 
symptoms of, 430 
treatment of, 431 
of skin, 327 et seq. 
Paresis in disseminated sclerosis, 945 

pathology of, 864 
Parkes, Dr., on blood in purpura, 565 
on cause of ague. 269 
on dysentery, 629 
on fever, 110 

on urea in urine in enteric fever, 109 
Parotitis (see Mumps), 147 
Parry, Dr. John S., on craniotabes, 842 



! 



Passive congestion, 101 
Pathology, definition of, 17 
general, part I. 17 et seq. 
special, part II, 131 et seq. 
Pavy, Dr.. on diabetes, 803, 804 
Peacock, Dr., on cyanosis, 509 
on intussusception, 678 
on malformation of heart, 511 
on measurement of orifices of heart, 
458 

on prognosis of cardiac diseases, 481 
Pectoriloquy, 365 
Pediculus capitis, 327 

pubis, 328 

tabescentium, 327 

vestimenti, 327 
Pelvic connective tissue, diseases of, 815 

organs, diseases of, 807 et seq. 

peritoneum, diseases of, 815 
Pemphigus (see Herpes), 306 

acute, 3 I 0 

causation of, 309 

chronic, 310 

description of. 309 

foliaceous, 3 1 0 

gangrsenosus (see Rupia), 311 
solitarius, 310 
treatment of, 311 
vulgaris, 310 
Pentastoma denticulatum, 786 
Pepper. Dr. William, on cholera infantum, 1 
Percussion, 353 
abnormal, 355 

bruit de pot fele, 357 
dulness, 355 
resistance, 358 
resonance, 356 
normal, 354 
dulness, 355 
resonance, 354 
Pereira, Dr., on removal of lead by skin, 5' 
577 

Pericarditis, 483 

causation of, 483 

morbid anatomy of, 484 

suppurative, 488 

symptoms and progress of, 486 

treatment of, 491 
Pericardium, adhesion of, diagnosis of, 476 

dropsy of, 502 

effusion into, diagnosis of, 475 

effect on fo'.m of pericardium, 466 

prognosis of, 476 

treatment of, 476 
haemorrhage into, 501 
inflammation of (see Pericarditis), 483 
syphilitic disease of, 493 
tubercle of, 493 
Periproctitis, 624, 627 
causation of, 627 
morbid anatomy of, 627 
symptoms and progress of, 628 
treatment of, 628 
Peritoneum, colloid cancer of, 648 
dropsy of (see Ascites), 685 
encephaloid cancer of, 649 
inflammation of (see Peritonitis), 635 
lymphadenoma of, 650 
malignant disease of (symptoms), 654 

treatment of, 654 
sarcoma of, 650 
scirrhus cancer of, 647 



INDEX. 1079 



Peritoneum, tubercle of, 643 

morbid anatomy of, 644 
symptoms and progress of, 645 
treatment of, 646 
Peritonitis, 635 

acute, 637 

adhesive, 640 

causation of, 635 

diagnosis of, 641 

in enteric fever, 217 

morbid anatomy of, 636 

perforative, 639 

puerperal, 639 

suppurative, 637 

symptoms and progress of, 637 

treatment of, 641 
Perityphlitis {see Typhlitis), 624 
Personal peculiarities as causes of disease, 23 
Pertussis (see Hooping-cou<rh), 143 
Pestilentia (see Plague), 186 
Petechiae, meaning of terra, 279 
Peter on inoculation of diphtheria, 201 
Petit raal (see Epilepsy), 999 
Pettenkofer on causes of cholera, 224 
Peyer's glands, affection of, in cholera, 232 

in enteric fever, 221 
Pharynx, abscess behind (see Retropharyngeal 

Abscess), 594 
Phlebitis, 526 

causation of, 526 

morbid anatomy of, 526 

symptoms of, 526 
Phlegmasia alba dolens, 533 
Phthiriasis, 327 

causation and description of, 327 

treatment of, 328 
Phthisis, abdominal (see Tubercle of Digestive 
0;gans) ; 642 

chronic pneumonic, 412 

fibroid (see Cirrhosis of Lungs), 405 

laryngeal. 375 

(See also Tubercle of Respiratory Or- 
gans), 409 

miners', millstone grinders', colliers', 

flax dressers', etc., 407 
pulmonary (see Tubercle of Respiratory 
Organs), 409 
Physaliphores, 82 

Physiological processes in disease, 37 
in health, 32 
tissues, 33 

Pia mater, inflammation of (see, Meningitis), 
900 

tubercle of (see Meningitis), 900 
Pictonum colica (see Lead-poisoning', Chronic), 
573 

Pigmentary degeneration, 91 
Pityriasis, 290 

rubra, 296, 298 
description of, 298 
treatment of, 298 
simplex, 292 

versicolor (see Tinea Versicolor), 337 
Plague, 186 

causation of, 186 

definition of, 186 

duration of, 187 

history of, 186 

morbid anatomy of, 187 

mortality of, 187 

resemblance of, to typhus, 187 

symptoms and progress of, 186 



1080 



Plague, treatment of, 187 
Plastic bronchitis, 383 

sputum, 348 
Pleure, air in (see Pneumothorax), 447 

anatomical relations of, 342 

dropsy of (see Hydrothorax), 440 
detection of, 369 

inflammation of (see, Pleurisy), 395 

morbid growths of (see Morbid Growths 
of Respiratory Organs), 425 

tubercle of (see Tubercle of Respiratory 
Organs), 409 
/r-f- Pleurisy, 395 

causation of, 395 

causes of death in, 401 

invasion of, 399 

morbid anatomy of, 396 

suppurative, 401 

symptoms and progress of, 399 

treatment of, 403 
Pleuritis (s-e Pleurisy), 395 
Pleurosthotonos, 1023 
Plica polonica, 327 

Plumbism (see Lead-poisoning, Chronic), 573 
_i Pneumonia, 385 

catarrhal. 386 
causation of, 385 
causes of death in, 390 
chronic (see Cirrhosis), 405 
complications of, 389 
croupous, 386 
idiopathic, 390 
lobar, 386 
lobular, 386, 388 

(Set also diphtheria), 209 
morbid anatomy of, 386 
mortality of, 394 
symptoms and progress of, 390 
treatment of, 394 
Pneumothorax. 447 
causation of, 447 
morbid anatomy of, 447 
symptoms and progress of, 448 
treatment of, 448 
Podagra (see Gout), 828 
Poland, Mr., on tetanus, 1020, 1023 
Pompholyx (see Pemphigus), 306 
Poore, Dr., on writer's cramp, 1050 
Porrigo decalvans (see Alopecia Areata), 337 
favosa (see- Tinea Favosa), 335 
larvalis (see Impetigo), 305 
lupinosa (see Tinea Favosa), 335 
scutulata (see Tinea Tonsurans), 333 
Portio dura, paralysis of, 1042 
causation of, 1042 
contraction of muscles after, 1044 
double, 1044 
epiphora in, 1043 
pain in connection with, 1043 
paralysis of soft palate in, 1044 
symptoms and progress of, 1042 
treatment of, 1045 
Precordium, change of area of dulness of, 473 
form of, 472 
increased resistance of, 473 
Predisposing cause, 21, 22 
Premonitory diarrhoea of epidemic cholera, 228 
Previous disease, as cause of disease, 24 
Priapism in myelitis and spinal meningitis, 

907, 915 
Privation as cause of disease, 24 
Prognosis (see different diseases) 



I 



Progressive muscular atrophy (see Muscular 

Atrophy, Progressive), 925 
Prophylactic treatment, 123 

of fevers, 137 
Prophylaxis, 124 
Protoplasm in health, 32 

vital properties of, 34 
Prout, Dr., on chyluria. 793, 794 

on the treatment of gallstones, 741 
Proximate cause, 21 
Prurigo, 340 

description of, 340 
treatment of, 340 

(See also Phthiriasis), 327 
Psammoma, 81 

Pseudohypertrophic paralysis, 846 
Psoriasis, 296 

causation of 296 
description of, 296 
diffusa, 297 
guttata, 297 
inveterata, 297 
lepra alphoides (alphos), 297 
gyrata, 297 
vulgaris, 297 
treatment of, 298 
Puerperal fever (see Pyaemia, Peritonitis, and 

Scarlet Fever) 
Pulex penetrans. 332 

Pulmonary apoplexy (see Hemorrhage of Re- 
spiratory Organs), 444 

collapse, 442 

causation and morbid anatomy of, 442 
symptoms and progress of, 444 
treatment of, 444 
varieties of, 442 

dropsy, 103, 441 

phthisis (see Tubercle of Respiratory Or- 
gans), 409 
tubercle, 409 
Pulmonic valve disease, diagnosis of, 474, 479 
effects of, on heart, 470 
prognosis of. 480 
treatment of, 482 
Pulsation, cardiac, in heart, disease, 473 
varieties of, 473 
hepatic, in heart disease, 1056 
Pulse, 461 

trace, 462 

varieties of in health, 464 

in heart disease, 461 

in aortic valve disease. 478 
varieties of as to force, 468 

as to frequency, 469 

in mitral valve disease, 480 

as to rhythm, 468 
Purpura, 563 

causation of, 563 
definition of, 563 
hemorrhagic, 564 
morbid anatomy of, 564 
simplex, 564 

symptoms and progress of, 563 

treatment of, 565 

urticans, 293 
Purring tremor, 473 
Pus, 53 

Pustule, Willan's fifth order. 282 
Pustules, meaning of term, 281 
Pyemia, 254 

bacteria in blood in, 258 

blood, condition of, in, 258 



INDEX. 



1081 



Pyaemia, bone nnd joint affection in, 256 
brain-affection in, 256 
causation of, 254 
definition of, 254 
diagnosis of, 261 

embolism and thrombosis in, 258 

heart, affection of, in, 256 

kidney, affection of, in, 256 

liver, affection of, in, 256 

lungs, affection of. in, 255 

morbid anatomy and pathology of, 255 

mortality of, 261 

spleen, affection of, in, 256 

symptoms and progress of, 209 

treatment of, 261 
Pyelitis, 769 

causation of, 769 

morbid anatomy of, 769 

suppurative, 770, 771 

symptoms and progress of, 770 

treatment of, 771 
Pyrosis, 696 



Quain Dr., on hypertrophy of heart in renal 

disease, 767 
Quartan ague, 272 
Quinine in ague, 277 
Quinsy, acute, 591 

causation of, 591 

morbid anatomy of, 591 

symptoms and progress of, 592 

treatment of, 593 
chronic. 593 

symptoms and progress of, 593 

treatment of, 631 
Quotidian ague, 272 



Rabies {see Hydrophobia), 236 

Rachitis {see Rickets), 837 

Radcliffe, Mr. N.. on cerebro spinal fever, 197 

on cholera, 227 
Rainey, Mr., on calcareous deposit, 93 

on emphysema, 437 
Rales, 366 

Ranke, on heat of body, 107 
Ransom, Dr., on thread-worms, 661 
Rash (exanthema), 280 
Rayer on diabetes insipidus, 805 
Recamier on hemiplegia in cerebral softening, 
975 

Rectum, ulceration of {see Periproctitis), 627 

Recurrent fibroid tumors, 81 

Red hepatization of lung, 387, 388 

induration of lung. 407 
Reflex action in paralyzed muscles, 870 
Relapsing fever, 187 

abortion in, 190 

causation of, 188 

causes of death in. 190 

convalescence protracted in, 190 

definition of. 187 

history of, 188 

incubation of, 189 

morbid anatomy of, 190 

mortality in, 190 

mortality in the negro race, 190 

sequelae of, 190 

symptoms and progress of, 189 
treatment of, 191 
Remedial treatment {see Therapeutical), 125 



Remittent fever {see Ague), 268, 274 
Renal dropsy, 103 

Renal disease {see Kidneys, diseases of), 751 

et seq. 
Repair, 51 

Reproductive organs, affection of, in hysteria, 
1014 

Respiration, pathology of, 344 

dyspnoea, 345 
Respiratory organs, diseases of, 341 et seq. 
in glanders, 241 
in leprosy, 267 
in pyaemia, 255 
tubercle of, 409 

causation of, 409 
causes of death in, 421 
morbid anatomy, 410 
morbid anatomy of cheesy or yel- 
low, 410 

morbid anatomy of gray or miliary, 
410 

morbid anatomy of laryngeal, 410 
morbid anatomy of pleural, 413 
morbid anatomy of pulmonary, 410 
symptoms and progress 414 
symptoms and progress of acute 

phthisis, 420 
symptoms and progress of chronic 

phthisis, 419 
symptoms and progress of pleural 

tubercle, 421 
treatment of, 421 
Retina, anaemia of, in epilepsy, 1002 
Retinal haemorrhage in renal disease, 768 
Retropharyngeal abscess. 594 
causation of, 594 
symptoms and progress of, 594 
treatment of, 594 
Reynolds, Dr. R , on epilepsy, 992 et seq. 
on hysterical paralysis, 1018 
on wry neck, 1049 
Rheumatic fever {see Rheumatism), 816 
Rheumatism, 816 

causation of, 816 
chorea in relation with, 985 
complications of, 819 
definition of, 816 

deltoid (see Deltoid Rheumatism), 1046 

heart disease in, 820 

lumbago, 818 

morbid anatomy of, 817 

pathology of, 822 

scarlet fever in relation with, 161 

sciatica. 818 

symptoms and progress of, 817 
torticollis, 818 
treatment of, 823 
Rheumatoid arthritis, 825 

causation of, 825 

definition of, 825 

morbid anatomy of, 825 

pathology of, 827 

symptoms and progress of. 826 

treatment of, 827 
Rhonchus, 367 

Rhythmical movements, 1019 

treatment of, 1020 
tremors in disseminated sclerosis, 943 

in mereurialism, 578 

in paralysis agitans, 949 
Richardson, Dr., on tetanus, 1024 
Rickets, 837 



1082 



INDEX. 



Rickets, causation of, 837 

definition of, 837 

morbid anatomy of, 837 

pathology of, 837 

symptoms and progress of, 841 

treatment of, 844 
Ricord on syphilis, 242 

Rigidity, muscular, in lateral sclerosis, 929 
in paralysis agitans, 950 

(See also various other affections of 
the cord and brain) 
Rigors, 110 

(See also Ague, and other febrile and in- 
flammatory disorders) 
Rilliet and Barthez, on rickets, 842 
Rindfleisch on carcinoma, 82 
on epithelioma, 86 
on lardaceous liver, 735 
on mollities ossium, 845 
on proud flesh, 51 
on tubercle, 75 
Ringworm (see Tinea Tonsurans), 333 
Risus sardonicus in spinal meningitis, 907 

in tetanus, 1021, 1022 
Roberts, Dr. W., on alkalinity of urine, 752 
on chyluria. 795 
on diabetes insipidus, 805 
on sugar in urine, 759 
on suppression of urine, 807 
on urea passed in nephritis, 780 
on uric acid calculi, 790 
Roe, Dr. H., on treatment of hooping-cough, 
146 

Roger, M., on chorea, 984 

on rickets, 842 
Rokitansky on malignant jaundice, 746 
Roseola (see Erythema), 290 

epidemic (see Epidemic Roseola), 153 
Rotheln (see Epidemic Roseola), 153 
Round worms, 661 

common, description of, 662 
symptoms of, 662 
treatment of, 663 
Rubeola (see Epidemic Roseola and Measles), 

149, 153 
Rupia, 311 

causation and description of, 311 
escharotica, 311 
prominens, 311 
treatment of, 31 1 
Rupture of heart (see Heart, Rupture of), 500 



St. Vitus's dance (see Chorea), 984 
Salisbury, Dr., on palmellae as cause of ague, 
270 

Salivary glands, affections of, in mumps, 147 
Salter. Dr. Hyde, on asthma, 451 et seq. 
Sanderson, Dr. Burdon, on cholera (experi- 
mental production of), 228 

on contagion of cow-pox, 136 

on localization of functions of brain, 852 

on lymphatic tissue, 71 

on lymphatic tissue and tubercle, 75 

on pulse-trace, 463 

on tubercle (experimental production of), 
77 

Sanguineous apoplexy, 966 
Sanies, 55 

Sarcina ventriculi, 653, 668, 696 

in urine, 765 
Sarcoma, 79 



Sarcoma of abdominal lymphatics, 650 
of bowels, 650 

of brain and cord (see Morbid Growths), 
952, 954 

cysto-, 80 

glio-, 80 

large-cell, 80 

lipomatous, 80 

of liver, 727 

melanoid, 81 

myxo-, 80 

osteo-, 79 

round-cell, 80 

of peritoneum, 650 

spindle-cell, 80 

of stomach, 650 
Scab, meaning of term, 282 
Scabies, 328 

acarus in, 328 

burrows or cuniculi in. 329 

causation and description of, 328 

Norvegica, 330 

treatment of, 331 
Scarlatina (see Scarlet Fever), 154 
Scarlet fever, 1 54 

albuminuria in, 161 

anginosa, 160 

causation of, 155 

complications and sequelee of, 160 

definition of, 154 

dropsy in, 161 

history of, 155 

incubation of, 155 

latent, 159 

malignant, 160 

morbid anatomy of, 161 

puerperal fever, relation of, with, 160 

rheumatism in, 161 

simple, 160 

symptoms and progress of, 155 
treatment of, 161 
Schiff. on cause of diabetes, 802 
Schmidt's saline solution for injection in 

cholera, 235 
Schunck on coloring matter in urine, 757 
Sciatica, 818, 1054 
Scirrhus, 83 

of bowel, stomach, and peritoneum, 647 
Scleriasis (see Scleroderma), 321 
Scleroderma, 321 

causation and description of, 321 
treatment of, 323 
varieties of, 322 
Sclerosis (of nerve-centres), 917 
disseminated, 941 

apoplectiform, attacks in, 947 
causation of, 942 
contraction of limbs in, 946 
definition of. 941 
expression in, 946 
eye-affection in, 944 
mental condition in, 946 
morbid anatomy of, 942 
paresis in, 945 
rhythmical tumors in, 943 
speech, affection of, in, 945 
stages of, 947 

symptoms and progress of, 943 
treatment of. 948 
vertigo in, 945 
lateral," 928 

causation of, 928 



INDEX. 



1083 



Sclerosis, lateral, definition of, 928 
morbid anatomy of, 928 
symptoms and progress of, 929 
treatment of, 932 

pathology of, 917 
Sclerostoma duodenale, 664 
Scolex of tape-worms, 655 et seq. 
Scorbutus (see Scurvy), 565 
Scrivener's palsy (see Writers Cramp), 1047 
Scrofula (see Tubercle of Lymphatics), 554 
Scurvy, 565 

causation of, 565 

definition of, 565 

morbid anatomy of, 567 

symptoms and progress of, 566 

treatment of, 567 
Seat-worm (see Thread worm), 663 
Seborrhoea, 312 

Sedgwick, Mr. W., on variations of urine in 

intestinal obstruction*, 682 
Seidel on galvanism in diabetes insipidus, 805 
Senator on urine in tetanus, 1022 
Septicaemia (see Pyaemia), 254 
Serous membranes, affections of, in pyaemia, 

256 

Sex, as cause of disease, 23 

Shaking palsy (see Paralysis Agitans), 948 

Sheep-pox. contagium of, 136 

Shingles (see Herpes), 306, 307 

Sibson, Dr., on reduplication of heart's sounds 

in renal disease, 767 
Sick headache (see Megrim). 1030 
Sight, affection of, in megrim, 1030 
Simon, Mr., on cancerous dyscrasia, 43 

on cvsts of kidney, 779 
Skin, diseases of, 278 et seq. 

in syphilis, 244, 246 
Skoda on bronchophony, 365 

on consonance, 362 

on tubular sounds, 362 
Small-pox. 163 

causation of, 163 

complications of, 166 

confluent, 165, 168 

contagium of, 137 

definition of, 163 

discrete, 165, 168 

history of, 163 

incubation of, 163 

inoculation of, 171 
on cattle, 172 

malignant, 169 

modified (varioloid), 169 

morbid anatomy of, 169 

mortality of, 169 

in pregnancy, 169 

secondary fever in, 169 

symptoms and progress of, 163 

treatment of. 170 
Smith, Dr. E., on mortality of hooping-cough, 
145 

Snow, Dr., on cause of cholera, 225 
Softening of brain (see Obstruction of Cerebral 

Arteries), 973 
Solitary glands, affection of, in cholera, 232 

in enteric fever, 219 
Spasm, 872 

of bronchial tubes (see Asthma), 450 
of larynx and trachea, 450 
treatment of, 450 
Spasmodic wry-neck (see W ry-neck) , 1047, 1048 
Spasms, local functional, 1047 



Spasms, tonic, in tetanus, 1022 
Specialized tissues. 35 
Specific causes of fevers, 131 

fevers, 131 et seq. 
Speech, defect of, in chorea, 986 

in disseminated sclerosis, 945 
in glosso-labio-laryngeal palsy, 939, 
940 

loss of power of, 885 

pathology of, 885 
Sphygmograph, 462 
Spina bifida (see Hydrorhachis), 979 
Spinal cord, affection of, in syphilis, 249 
dropsy (see Hydrorhachis), 978 
epilepsy in disseminated sclerosis, 946 
haemorrhage, 963 
causation of, 963 
morbid anatomy of, 963 
symptoms and progress of, 971 
treatment of, 971 
irritation, 1015 
nerves, paralysis of. 1045 
causation of, 1045 
symptoms and diagnosis of, 1046 
treatment of, 1 047 
paralysis, adult (see Paralysis, Spinal 

Adult), 922 
paralysis, general (see Paralysis, Spinal 
General), 923 
infantile (see Paralysis, Spinal Infan- 
tile), 918 

Spine, affection of, in hysteria, 1015 
Spirilla in blond in relapsing fever, 136 
Spirometry, 370 
Splashing, 368 
Spleen, in ague, 275, 276 
atrophy of, 547 
congestion of, 544 
causation of, 544 
morbid anatomy of, 544 
symptoms and progress of, 544 
treatment of, 545 
cysts of, 547 
diseases of, 543 et seq. 
hypertrophy of, 545 
causation of, 545 
in enteric fever, 221 
morbid anatomy of, 545 
in relapsing fever, 191 
symptoms and progress of, 545 
treatment of. 546 
inflammation of, 543 
causation of, 543 
morbid anatomy of, 543 
symptoms of, 543 
treatment of, 544 
lardaceous degeneration of, 547 
morbid anatomy of, 547 
symptoms of, 548 
treatment of, 548 
morbid growths of. 546 

symptoms of, 547 
tubercle of, 546 
Splenic fever, fungi in blood in, 136 
Spread of epidemic and endemic diseases, 
131 

Sputa (see Expectoration), 347 

Squamae, meaning of term, 282 
Willan's second order, 282 

Squinting in oculo-motor paralysis (see also 
Meningitis, Tabes Dorsalis, and other ner- 
vous diseases), 1039 



1084 



INDEX. 



Squire, Dr., on latency of influenza, 140 

Mr. B., on pediculi, 327, 328 
Stiideler on bile and blood pigment, 92 
Startin, Mr. Jas.. on treatment of lupus, 318 
Status epilepticus, 998 
Stethoscope, 358 
Stigma, meaning of term, 279 
Stokes, Dr., on treatment of bronchitis, 384 
Stomach, cirrhosis of, 642 
symptoms of, 642 
degenerative affections of. 667 
haemorrhage from (see Haemorrhage from 

Stomach and Bowels), 689 
inflammation of (see Gastritis), 604 
malignant disease of, 647 
colloid, 648 
encephaloid, 649 
lymphadenoma, 650 
sarcoma, 650 
scirrhus, 647 
symptoms of. 652 
treatment of, 654 
obstruction of, 667 
causation of, 667 
morbid anatomy of, 667 
symptoms and progress of. 668 
treatment of. 669 
ulceration of, 614 
causation of, 614 
haemorrhage in, 617 
morbid anatomy of, 615 
perforation in. 617 
symptoms and progress of, 616 
treatment of, 617 
Stomatitis gangrenosa (see N<>ma and Gan- 
grene of Fauces), 587, 588 . 
ulcerative, 586 
causation of, 586 
morbid anatomy of, 586 
symptoms and progress of, 586 
treatment of, 587 
Stone, Dr., on se^ophony, 366 
Strangulation, internal, of bowels, 674 
causation of, 674 
morbid anatomy of, 674 
symptoms of, 675 
treatment of, 682 
Stricture of bowels, 671 
causation of, 671 
morbid anatomy of, 671 
results of, 671 

symptoms and progress of, 672 
treatment of, 682 
of oesophagus, 598, 600 
Stridulous laryngitis, 374, 376 
Strongylus gigas 786 
Strophulus (see Eczema), 300 

albidus (see Acne), 312 
Suecussion, 368 
Sudamina, 306 
Sugar in urine, 758 

tests for, 758 
(See also Diabetes), 798 
Sunstroke, 1025, 1028 
causation of, 1028 
definition of, 1028 
morbid anatomy of, 1029 
pathology of, 1029, 1030 
symptoms and progress of, 1028 
treatment of, 1029, 1030 
Suppression of urine (see Urine, Suppression 
of), 805 



Suppression of urine, in cholera, 229 

in enteritis, 681 

in hysteria, 1014 
Suppuration, 53 

Suprarenal capsules, diseases of, 548 et seq. 
morbid growths of, 552 
tubercle of (see Addison's Disease), 548 
Sutton, Dr., on cholera stools, 230 
Sycosis (see Acne), 313 

(See Impetigo), 305 

{See Tinea Tonsurans), 334 
Sydenham on treatment of chorea, 991 
Sympathetic system, influence of, over 

morbid processes, 875 
Syncope, 116, 117, 502 

causation of. 5(12 

symptoms of, 116 

treatment of, 503 
Syphilis, 241 

causation of. 241 

communicated by vaccination, 175 
definition of. 241 
history of, 241 

incubation of. 243 ♦ 
inherited, 250 

abortion in connection with, 250 
affection of teeth in, 251 
keratitis in, 251 
inoculation of. 243, 255 
morbid anatomy and pathology of, 251 
primary symptoms of, 243 

Hunterian chancre, 248 
lymphatic gl mds, affection of, 244 
protection afforded by. one attack, 243 
secondary symptoms of, 244 
corona veneris, 245 
eruptive stnge, 244 
erythema eircinatum, 244 
eye affection. 245 
mucous tubercles, 245 
nodes, 245 
psoriasis, 244 
pustules, 244 
roseola, 244 
tubercles, 244* 
vesicles and blebs, 244 
sequelae of, 250 

symptoms and progress of, 243 
tertiary symptoms of, 246 
gummata, 246 

involving internal organs, 249 
locomotor organs, 248 
mucous membranes, 247 
skin, 246 
testes, 249 

transmission of. from parent to children, 
242 

treatment of, 252 
Syphilitic disease of brain and cord (see Mor- 
bid Growths of Brain and Cord), 
952, 953 
of heart, 493 

symptoms of, 494 
of kidney, 784 
of larynx, 375, 423 

of liver (see Morbid Growths of Liverl, 
724 

of mouth, fauces, etc., 595 
of respiratory organs, 424 
of bronchial tubes, 423 
of larynx, 423 
of lungs, 423 



INDEX. 



1085 



Syphilitic disease of trachea, 423 

symptoms and progress of, 424 
treatment of, 425 



Tabes dorsalis, 932 

causation of, 932 

definition of, 932 

morbid anatomy of, 932 

symptoms and progress of, 933 

treatment of, 938 
Tache cerebrale. 895, 906 
Taenia echinococcus, description of, 659 
niediocanellata, description of, 657 

symptoms of, 658 

treatment of, 658 
solium, description of, 656 

symptoms of, 658 

treatment of, 658 
Tseniada, general account of, 655 
Tapeworms, general account of, 655 
Taylor, Dr. A. S., on lead poisoning, 573, 576 

Dr. F., on hepatic pulsation, 1056 
Teale, Mr., on spinal irritation, 1015 
Teeth, affection of, in congenital syphilis, 251 
Temperature, abnormal, 108 

in collapse, 117 

death from, 111 

degradation of tissues as cause of, 111 
in hectic fevsr, 1 13 

symptoms referable to circulatory or- 
gans, 110 

digestive organs, 109 
nervous system. 110 
respiratory organs, 109 
skin. 108 

urinary organs, 109 
in typhoid condition, 115 
variations of, 108 
normal, 106 
cause of, 106 
regulation of, 107 
(See also the different diseases) 
Tertian ague, 272 

Testicle, affection of, in leprosy, 267 
mumps, 148 
syphilis, 249 
Tetanus, 1020 

causation of, 1020 
definition of, 1020 
diagnosis of, 1023 
emprosthotonos in, 1023 
morbid anatomy of, 1023 
opisthotonos in, 1023 
pleurosthotonos in, 1023 
prognosis of, 1023 
risus sardonicus in, 1021, 1022 
stiffness of muscles in, 1021 
symptoms and progress of, 1021 
temperature in, 1022 
tonic spasms in, 1021, 1022 
treatment of, 1024 
trismus or lockjaw in, 1023 
Therapeutical treatment, 125 

administration of nourishment, 128 
elimination of poisonous matter, 128 
maintenance of strength, 127 
obviation of tendency to death, 130 
protection to sick, 126 
of secondary phenomena or symptoms, 
129 

Thermic fever, 1030 



Thermometer, use of. 112 

Thiersch, on experimental production of 

cholera, 227 
Threadworm, common, description of, 663 
symptoms of, 663 
treatment of, 663 
Thrill, hydatid. 731 
Thrombosis, 528 

causation <>f, 528 

of cerebral arteries (see Cerebral Arteries, 

Obstruction of), 973 
morbid anatomy of, 528 
in arteries, 530 
in heart, 528 
in veins, 529 
in pyaemia (s?e Pyaemia), 258 
symptoms of, 532 
cardiac, 533 
multiple, 535 
pulmonic, 534 
systemic arterial, 535 
systemic venous, 532 
treatment of, 533,535 
of venous sinuses, 955 
Thrush, 584 

causation of, 584 
morbid anatomy of, 584 
oidium albicans in, 585 
symptoms and progress of, 585 
treatment of 586 
Thudichum, Dr., on blood in cholera, 233 

on gallstones, 737 
Thyroid bod}-, carcinoma of, 536 
diseases of, 536 

hypertrophy of (see Goitre), 536 

(See also Graves's Disease,) 503 
inflammation of, 536 
Tic douloureux, 1053 

symptoms of, 1053 
treatment of, 1054 
Tinea decahans (see Alopecia Areata), 337 
favosa, 335 

achorion Schonleinii in, 335 
causation of. 335 
description of, 335 
treatment of, 336 
tonsurans, 333 
causation of, 333 
description of, 333 
treatment of, 335 
tricophyton tonsurans in, 333 
versicolor, 337 
causation of, 337 
description of. 337 
microsporon furfur in, 337 
treatment of, 337 
Tinkling, metallic, 363 
Tissues, connective, 33 
epithelial, 33 
physiological, 33 
specialized, 33 
Todd, Dr., on alcohol in pneumonia, 394 

on hemiplegia in cerebral softening, 975 
Tone of paralyzed muscles, 868 
Tongue, enlargement of, in children, 559 

inflammation of (see Glossitis), 589 
Tonic spasms, description of, 873 
Tonsil, inflammation of (see Quinsy), 591 

in scarlet fever, 156, 160 
Tonsillitis (see Quinsy), 591 
Tophi (see Gout), 829 
Torticollis, rheumatic, 817 



1086 



INDEX. 



Torticollis, spasmodic (see Wry -neck), 1047 
Torula cerevisiae (yeast-plant) in urine, 765 

in vomit, 696 
Trachea, congestion of (see Congestion of Res- 
piratory Organs), 439 
diphtheritic aifection of, 203 
inflammation of (see Tracheitis), 377 
spasm of, 450 

syphilitic disease of (see Syphilitic Disease 
of Trachea), 423 
Tracheitis, 377 

causation of, 377 

morbid anatomy of, 377 

symptoms of, 377 

treatment of, 377 
Tracheotomy in diphtheria, 210 
Traction of bowel (see Compression of Bowel), 
673 

Trapp's formula for determining solids in 

urine, 753 
Treatment of disease, 123 
hygienic, 123 
prophylactic, 123 
therapeutical, 125 
(See also the different diseases) 
prophylactic, of fevers, 137 
(See also different diseases) 
Tremor, purring, in heart disease, 473, 479 
Tremors, 873 

in disseminated sclerosis, 943 
in mercurial poisoning, 578 
in paralysis agitans, 949 
Trendelenburg on inoculation of diphtheria, 
201 

Trichina spiralis, description of, 664 
Trichinosis. 664 

symptoms and progress of, 665 

treatment of. 666 
Tricophyton tonsurans, 333 
Tricuspid valve disease, diagnosis of, 474, 480 
effects of, on heart, 471 
prognosis of, 480 
treatment of, 482 
Trismus (^Tetanus), 1020 

neonatorum, 1024 
Trommer's test for sugar, 758 
Trousseau on adenia, 557 

on anaemia, 561 

on aphasia, 890 

on belladonna in hooping-cough, 146 

on chorea, 984 

on constipation, 682 

on delirium in small-pox, 169 

on delirium tremens, 568 

on diabetes insipidus, 804, 805 

on diarrhoea, 701, 706 

on diarrhoea in dyspepsia, 696 

on dysentery, 634 

on epidemic roseola, 153 

on epilepsy, 992, 997, 1003 

on Graves's disease, 506 

on hemiplegia in cerebral softening, 975 

on hooping-cough, 145 

on hydrocephalic cry, 904 

on hydrocephalus, 980 et seq. 

on hydrochloric acid in diphtheria, 209 

on inoculation of diphtheria, 201 

on mollities ossium, 845 

on multiple puncture of hydatid cysts, 732 

on painful spots in neuralgia, 1051 

on paracentesis thoracis, 403 

on paralysis agitans, 952 



Trousseau on recovery of arm before leg in 
hemiplegia, 971 

on rheumatoid arthritis, 827 

on swelling of hands and feet in confluent 
small-pox, 168 

on tabes dorsalis, 936 

on tache cerebrale, 895, 906 
Tubercle, 73 

of abdominal lymphatic glands, 643 

of bowels (see Bowels, Tubercle of), 642 

of brain and cord (see Morbid Growths of 
Brain and Cord), 952 

crude or yellow, 74 

cutaneous, meaning of term, 280 

of digestive organs, 642 et seq. 

of Fallopian tubes, 810 

in glanders, 240 

gray or miliary, 74 

of heart and pericardium, 493 
symptoms of, 493 

inoculation of, 77 

of kidney (see Kidney, Tubercle of), 782 
Klein, Dr., on (note), 78 
of larynx (see Respiratory Organs, Tu- 
bercle of), 409 
of liver, 723 

of lungs (see Respiratory Organs, Tubercle 
of), 409 

of lymphatics (see Lymphatics, Tubercle 

of), 554 
microscopic description of, 74 
of meninges (see Meningitis), 900 
of mouth, fauces, etc., 595 
of ovaries, 810 

of peritoneum (see Peritoneum, Tubercle 

of), 643 

of pleura (see Respiratory Organs, Tuber- 
cle of), 409 
quasi- malignancy of, 77 
relation to adenoid tissues, 76 
relation between gray and crude, 76 
seat of, 74, 78 

of spleen (see Spleen, Tubercle of), 546 

of suprarenal capsules (see Addison's 
Disease), 548 

of urinary bladder, 808 

of uterus, 810 
Tuberculse, Willan's seventh order, 280 
Tubercular laryngitis (see Laryngitis), 374 

meningitis (see Meningitis), 900 
Tuberculosis (see Tubercle), 73 
Tubular breathing, 361 
Tumors, adenoid, 86 

angioma or vascular, 67 

carcinoma, 81 

chondroma or cartilaginous, 65 
classification of, 61 
colloid, 84 
complex, 62 
connective tissues, 63 
encephaloid, 34 
epithelioma, 85 
fibroma or fibrous, 63 
glioma or glue like, 64 
granuloma, 73 
gummata, 78 
histioid, 62 
lipoma or fatty, 63 
lymphadenoma, 69 
lymphangioma, 69 
lymphoma or lymphatic, 68 
myoma or muscular, 67 



INDEX. 



1087 



Tumors, myxoma or mucous, 64 

neuroma or nervous, 66 

organoid, 62 

osteoma or osseous, 66 

sarcoma, 79 

scirrhus, 83 

scrofulous glands, 69 

teratoid, 62 

tubercle, 73 
(See also different organs) 
Type, change of, in disease, 26 
Typhlitis, 624, 625 

causation of, 625 

morbid anatomy of, 625 

symptoms and progress of, 626 

treatment of, 627 
Typhoid condition, 114 
symptoms of, 114 
Typhoid fever (see Enteric Fever), 210 
Typhus, 178 

abdominal (see Enteric Fever), 210 

causation of, 178 

causes of death in, 184 

complications of, 184 

definition of, 178 

history of, 178 

incubation of, 179 

morbid anatomy of, 184 

mortality of, 184 

pregnancy and, 183 

symptoms and progress of, 180 

treatment of, 185 

varieties of, 183 
Tyrosin, 756 



Ulceration, 55 

of bowels (see Bowels, Ulceration of), 618 
(See also Enteric Fever, and Tubercle 
of Bowels) 
of bronchial tubes, 378, 410 
ofctecum (see, Typhlitis) , 624 
of colon (see Dysentery), 628 
of duodenum, 624 
of larynx, 371, 410 
of mouth, 584, 586, 587 
of oesophagus, 597 
of rectum (see Periproctitis), 627 
of stomach (see Stomach, Ulceration of), 
61t 

of trachea, 377, 410 
Ureemia, 768 

in scarlet fever, 161 
in suppression of urine, 805 
in the typhoid condition, 116 
Urates deposited in gout, 829 
in urine, 755 

forms of, 756 
tests for. 756 
Uratic calculi, 765 

degeneration, 92 
Urea, 755 
Uric acid, 755 

calculi, 765 
Urinary bladder, diseases of, 807 
dilatation of, 808 

symptoms of, 808 
treatment of, 809 
inflammation of, 807 
morbid growths of, 808 
tubercle of, 808 
concretions, 788 



Urinary bladder, concretions, causation of, 788 
chemistry of, 765 

ammoniaco - magnesian phosphate, 
766 

amorphous phosphate, 766 
carbonate of lime, 766 
cystin, 765 
fusible, 766 
oxalate of lime, 765 
uratic, 765 
uric acid, 765 
xanthin, 765 
morbid anatomy of, 788 
symptoms and progress of, 789 
treatment of, 790 
organs, affection of, in hysteria, 1014 
Urine, bloody (see Hematuria, and Parox- 
ysmal Hematuria), 795, 796 
chylous (see Chyluria), 793 
in disease, 754 

albumen in, 760 

ammoniaco-magnesian phosphate in, 
760 

amorphous phosphate of lime in, 760 

bacteria in, 765 

Bilharzia haematobia in, 765 

blood in, 762 

carbonate of lime in, 760 

casts in, 763 

chyle in, 793 

coloring matter of blood in, 762 
coloring matters in, 757 
crystallized phosphate of lime in, 760 
cystin in, 756 
echinococci in, 764 
fat in, 764 
hydatids in, 764 
leucin in, 756 
morbid growths in, 764 
mucus in, 763 
odorous matters in, 758 
oxalate of lime in, 760 
penicilliuua. 765 
physical characters of, 754 
pus in, 763 
quantity of, 754 
quantity of solids in, 754 
reaction of, 754 
salts in, 760 
sarcinse in, 765 
specific gravity of, 754 
spermatozoa in, 764 
sugar in, 758 
tyrosin in, 756 
urates in, 755 
urea in, 755 
uric acid, 755 
xanthin in, 756 
yeast-plant in, 765 
in health, 752 

constituents of (enumeration), 753 
determination of solids in, 753 
quantity of, 752 
specific gravity of, 753 
retention of constituents of, in blood, con- 
sequences of, 766 

anasarca, 768 

congestion, 768 

dropsy, 768 

haemorrhage, 768 

hypertrophy of heart, 767 

inflammation, 768 



1088 



INDEX. 



Urine, retention of constituents of, in blood, 
thickening of bloodvessels, 767 
uraemia. 76S 
suppression of, 805 
in cholera, 229 
functional, 805 
in hysteria, 1014 
from obstruction of ureters, 805 
symptoms and progress of, 800 
treatment of, 806 
in obstruction of bowels, 681 
Urticaria (see Erythema 290), 294 
evanida, 294 
factitious, 295 
febrilis, 294 
perstans, 295 
treatment of, 295 
Uterus, dilatation of, 81 I 
inflammation of, 809 
causation of, 809 
morbid anatomy of. 809 
symptoms of, 809 
malignant disease of, 814 
myomata of, 810 

symptoms of, 810 
tubercle of, 810 



Vaccination, 171 

dangers of, 1 75 

history of. 174 

Jenner, Dr. E., on, 174 

Marson, Mr. , on, 1 75 

performance of, 176 

precautions as to, 176 

protectiveness of, against variola, 174 

repetition of, 1 76 
Vaccine lymph, mode of taking. 176 

vegetable organisms in, 137 
Vaccinia (see Cow-pox), 171 

experiments with regard to the contagium 
of, 136 

Valleix on painful spots in neuralgia, 1052 
Valves of heart, degenerative affections of, 
497 

causation of, 497 
morbid anatomy of, 497 
symptoms of, 498 
treatment of, 499 
rupture of, 501 
Valvular lesions (see the several valves) 
Varicella (see Chicken-pox), 177 
Variola (see Small-pox), 163 
Varioloid (see Small-pox), 163 
Varix, 527 

causation of, 527 
morbid anatomy of, 527 
Vascular system, diseases of, 457 et seq. 

tumors, 67 
Veins, dilatation of (see Varix), 527 
diseases of, 526 et seq. 
embolism of (see Embolism), 530 
obstruction of, 528 
thrombosis of (see Thrombosis), 528 
Venous murmur, 475 

sinuses, obstruction of, 959 
Ventricles of brain and cord, anatomy of, 849 
dropsy of (see Hydrocephalus and 

Hydrorhachis), 978 
effusion of blood into, 965, 969 
of heart, diseases of (see Heart, etc.) 
Verruca necrogenica, 317 



Vertebrae, caries of (see Dura Mater, Inflatn 

mation of), 892, 896 
Vertigo, 884 

aural (see Meniere's Disease), 1034 

epileptic, 996 

in disseminated sclerosis, 945 

in morbid growths of brain, 9 56 

pathology of, 884 

varieties of, 884 
Vesicles, meaning of term, 281 
Vesiculse (Wilan's sixth order), 281 
Vesicular emphysema (see. Emphysema), 434 
Vibices, meaning of term, 279 
Villemin on inoculation of tubercle, 77 
Virchow on carcinoma, 81 

on catarrh of hepatic ducts, 745 

on cell districts, 34 

on classification of tumors, 62 

on cretinism, 539 

on elephantiasis, 324 

on elephantiasis Arabum, 69 

on enchonclroma, 65 

on erysipelas, 286 

on fibrin in inflammation, 44 

on glioma. 64 

on goitre, 537 

on goitre (submaxillary), 539 
on granuloma, 73 
on hyperplasia, 46 
on jaundice, 712 
on keloid, 319 

on lardaceous degeneration, 89 

on leprosy, 266, 267 

on leucocythemia, 73 

on mollities ossium, 845 

on molluscum contagiosum, 326 

on physiological tissues, 33 

on psammoma, 81 

on pyaemia, 258 

on sarcoma, 79 

on scrofulous glands, 70 

on syphilitic disease of liver, 724 

on tongue enlargement in children, 559 

on tubercle, 76 

on tubercle of oral mucous membrane, 

595 

on white hepatization of lungs, 424 
Vital causes of disease, 30 

properties of protoplasm, 35 
Vitiligoidea (see Xanthoma), 319 
Vocal fremitus, 352 
Vogel, Alfred, on urea in pyaemia, 109 
Voice, absence of, 343 

auscultation of, 360, 364 

in cholera, 229 

feebleness of, 343 

in leprosy, 264 

pathology of, 343 

pitch of, 344 

quality of, 344 
Volkmann? on infantile paralysis, 921 
Volvulus, 685 

causation of, 685 

symptoms of, 685 

treatment of, 685 
Vomicae, detection of, 369 

(See also Pneumonia, Cirrhosis, Tubercu- 
lar Disease, and Morbid Growths of the 
Lungs) 

Vomit, black, in yellow fever, 194 
Vomiting, of blood (see Haemorrhage from 
Stomach), 689 



INDEX. 



1089 



Vomiting, in dyspepsia, 695 

in epidemic cholera, 229 

in hysteria, 1014 

in megrim. 1031 

in Meniere's disease, 1035 

in morbid growths of brain, 956 

in obstruction of bowels, 672 

in obstruction of stomach, 668 

in tubercular meningitis, 903 

(See also various affections, especially 
of stomach and bowels) 
Von B'arensprung on zona, 307 



Wagstaffe, Mr., on collapse temperatures, 117 
Warehouseman's itch (see Eczema, 300), 302 
Wasting palsy (see Muscular Atrophy, pro- 
gressive), 925 
Water on the brain (see Hydrocephalus), 978 
Water on the chest (see Hydrothorax, 440, 

and Hydropericardium, 502) 
Watson, Dr. Eben, on nitrate of silver in 

hooping-cough, 146 
Watson, Mr. Spencer, on cystic goitre, 537 
Watson, Sir Thomas, on ague, 269, 276 

on apoplexy, 972 

on catarrh, 583 

on chorea, 987, 991 

on hydrocephalus, 984 

on hysteria, 1013, 1017 

on lead-poisoning, 578 

on meningitis, 909 

on tetanus, 1021, 1024 
Waxy degeneration (see Lardaceous Degenera- 
tion) 

Weber, Dr. H., on hyperpyrexia, 821 
Weigert on contagium of small-pox, 137 
Wells, Mr Spencer, on ovarian tumors, 814 
Wens, 313 

Werlhofii, morbus maculosus (see Purpura), 
563 

West, Dr. C, on infantile convulsions, 1005 

on infantile paralysis, 920 
Wheal, definition of, 280 
Whipworm, description of, 663 
White hepatization of lungs, 424 
White-cell blood (see Leucocytbaemia), 73, 557 
Wilks, Dr., on ansemia lymphatica, 557 

on delirium tremens, 572 

on encephalitis, 912 

on verruca necrogenica, 317 
Willan on classification of skin diseases, 279 

on erythema and roseola, 290, 293 

on lepra and psoriasis, 296 



Willan on prurigo, 340 

on strophulus albidus, 313 
Wilson, Mr., on classification of skin diseases, 
279 

Wood, Dr. H. C, on heat or thermic fever, 
1030 

Worms, intestinal, 655 et seq. 
Wrist-drop (see Lead-poisoning). 573, 575 
Writer's cramp, 1047 

pathology of, 1049 

treatment of, 1050 
Wry-neck, spasmodic, 1047, 1048 

pathology of, 1049 

treatment of, 1050 
Wunderlich, on temperature in enteric fever, 
216 

Wyman, Dr. Morrill, on autumnal catarrh, 456 



Xanthelasma (see Xanthoma), 319 
Xanthin calculi, 765 

chemistry of, 756 
Xanthoma. 319 

inherited, 320 

causation of, 319 

connection with jaundice, 320, 713 
description of, 319 
planum, 319 
tuberosum, 319 
Xeroderma (see Ichthyosis), 298 



Yellow atrophy of liver (see Jaundice, Malig- 
nant), 746 
Yellow fever, 193 

contagiousness of. 193 

causation of, 193 

death, causes of, in, 194 

definition of, 193 

diagnosis of, 195 

history of, 193 

incubation of, 194 

morbid anatomy of, 195 

mortality of, 194 

symptoms and progress of, 194 

treatment of, 196 



Zenker on degeneration of muscle, 88 

on trichinosis, 664 
Zona (see Herpes Zoster), 306, 307 
Zoster (see Herpes Zoster), 306, 307 
Zymotic diseases (see Specific Febrile Dis- 
eases), 131 



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